Immunizations Forms
Copyright 2010 Well Trained Mind
Certificate of Immunization Status (CIS)
Child’s Last Name :
First Name :
Middle Initial :
Child’s Birthdate :
Child’s Sex :
Child’s Address :
Parent/Guardian Name :
Parent/Guardian Day Phone :
If completing by hand, write the vaccine in the row to the left of “Dose” and the date the vaccine was received in the “Date” column. Age column is optional.
- Required for School and Child Care/Preschool
- Required for Child Care/Preschool Only
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Vaccine :
Hepatitis B (Hep B)
Vaccine :
Vaccine :
Vaccine :
Dose :
Dose :
Dose :
Dose :
Date :
Date :
Date :
Date :
Age :
Age :
Age :
Age :
Vaccine :
Hepatitis B (Hep B) Alternate schedule for teens
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Rotavirus
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Diphtheria, Tetanus, Pertussis (Tdap, Td)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Haemophilus influenzae type b (Hib)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
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Vaccine :
Pneumococcal (PCV, PPV)
Vaccine :
Vaccine :
Vaccine :
Dose :
Dose :
Dose :
Dose :
Date :
Date :
Date :
Date :
Age :
Age :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Polio (IPV, OPV)
Vaccine :
Vaccine :
Vaccine :
Dose :
Dose :
Dose :
Dose :
Date :
Date :
Date :
Date :
Age :
Age :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Influenza (most recent)
Vaccine :
Vaccine :
Dose :
Dose :
Dose :
Date :
Date :
Date :
Age :
Age :
Age :
Vaccine :
Measles, Mumps, Rubella (MMR)
Vaccine :
Vaccine :
Dose :
Dose :
Dose :
Date :
Date :
Date :
Age :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Varicella (chickenpox)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
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Vaccine :
Hepatitis A (Hep A)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Meningococcal (MCV4, MPSV4)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Human Papillomavirus (HPV)
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Other
Vaccine :
Dose :
Dose :
Date :
Date :
Age :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
Vaccine :
Dose :
Date :
Age :
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Verification of varicella disease history
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No HCP Sig required if box at left
Date :
If school staff find verification in the Registry, then school staff must:
Either initial with parent approval or get parent signature below :
Staff initials indicating parent approval :
Parent Signature indicating approval :
ONLY acceptable for some grades. Write date or age child had disease:
Child Age :
or
Date :
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Documentation of Immunity by Blood Test (titer)
I certify that the child named on this form has laboratory evidence of immunity to (check all that apply):
Typed or Printed Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)
Name of Licensed Health Care Provider :
Date :
Vaccine Trade Names*
Read down and across - Trade Names are in Alphabetical Order.
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Trade Name
Vaccine
Acel-Imune
DTaP
ActHIB
Hib
Adacel
Tdap
Boostrix
Tdap
Certiva
HPV
Comvax
Hib + Hep B
Daptacel
DTaP
Decavac
Td
Engerix-B
Hep B
Fluarix
Flu
FluMist
Flu
Fluvirin
Flu
Fluzone
Flu
Gardasil
HPV
Havrix
Hep A
HibTITER
Hib
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Trade Name
Vaccine
Menomune
MPSV4
OmniHIB
Hib
Pediarix
DTaP + IPV + Hep B
PedvaxHIB
Hib
Pentacel
DTaP + IPV + Hib
Pentavalente
DTaP + Hep B + Hib
Pneumovax
PPV23
Prevnar
PCV or PCV7
ProHIBiT
Hib
ProQuad
MMRV
Quadracel
DTaP + IPV
Recombivax
Hep B
Rotarix
Rotavirus
RotaTeq
Rotavirus
Tetramune
DTP + Hib
TriHIBit
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DTaP + Hib
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Abbreviations
Full Vaccine Name
DT
Diphtheria, Tetanus
DTaP
Diphtheria, Tetanus, acellular Pertussis
DTP
Diphtheria, Tetanus, Pertussis
Flu (TIV or LAIV)
Influenza
HBIG
Hepatitis B Immune Globulin
Hep A (HAV)
Hepatitis A
Hep B (HBV)
Hepatitis B
Hib
Haemophilus influenzae type b
HPV
Human Papillomavirus
IPV
Inactivated Poliovirus Vaccine
MCV4
Meningococcal Conjugate Vaccine
MPSV4
Meningococcal Polysaccharide Vaccine
MMR
Measles, Mumps, Rubella
MMRV
Measles, Mumps, Rubella, Varicella
OPV
Oral Poliovirus vaccine
Vaccine Trade Names*
Read down and across - Trade Names are in Alphabetical Order.
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HyperTET
TIG
HyperHEP B
HBIG
Ipol
IPV
Infanrix
DTaP
Kinrix
DTaP + IPV
Menactra
MCV4
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Tri-Immunol
DTP
Tripedia
DTaP
Twinrix
Hep B + Hep A
Vaqta
Hep A
Varivax
Varicella
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PCV or PCV7
Pneumococcal Conjugate Vaccine
PPV23
Pneumococcal Polysaccharide Vaccine
Rota (RV1 or RV5)
Rotavirus
Td
Tetanus, Diphtheria
Tdap
Tetanus, Diphtheria, acellular Pertussis
TIG
Tetanus immune globulin
VAR or VZV
Varicella
*These lists may not be comprehensive; visit http://www.doh.wa.gov/cfh/immunize/forms/default.htm for updated lists. DOH 348-013 Revised: 10/15/08
