Get Wi F-44192 2017

04 Wis. Stats. DAY CARE IMMUNIZATION RECORD COMPLETE AND RETURN TO DAY CARE CENTER. State law requires all children in day care centers to present evidence of immunization against certain diseases within 30 school days 6 calendar weeks of admission to the day care center. See Waivers below. If you have any questions on immunizations or how to complete this form please contact your child s day care provider or your local health department. PERSONAL DATA STEP 1 PLEASE PRINT Child s Name Last First Middle Initial Date of Birth Month/Day/Year Area Code/Telephone Number Name of Parent/Guardian/Legal Custodian Last First Middle Initial Address Street Apartment number City State Zip IMMUNIZATION HISTORY STEP 2 List the MONTH DAY AND YEAR the child received each of the following immunizations. DO NOT USE A 4 OR X except to indicate whether the child has had chickenpox. If you do not have an immunization record for this child contact your doctor or local public health department to obtain the records. These requirements can be waived only if a properly signed health religious or personal conviction waiver is filed with the day care center. See Waivers below. If you have any questions on immunizations or how to complete this form please contact your child s day care provider or your local health department. PERSONAL DATA STEP 1 PLEASE PRINT Child s Name Last First Middle Initial Date of Birth Month/Day/Year Area Code/Telephone Number Name of Parent/Guardian/Legal Custodian Last First Middle Initial Address Street Apartment number City State Zip IMMUNIZATION HISTORY STEP 2 List the MONTH DAY AND YEAR the child received each of the following immunizations. DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44192 Rev* 09/08 STATE OF WISCONSIN ss. 252. These requirements can be waived only if a properly signed health religious or personal conviction waiver is filed with the day care center. See Waivers below. If you have any questions on immunizations or how to complete this form please contact your child s day care provider or your local health department. PERSONAL DATA STEP 1 PLEASE PRINT Child s Name Last First Middle Initial Date of Birth Month/Day/Year Area Code/Telephone Number Name of Parent/Guardian/Legal Custodian Last First Middle Initial Address Street Apartment number City State Zip IMMUNIZATION HISTORY STEP 2 List the MONTH DAY AND YEAR the child received each of the following immunizations. DO NOT USE A 4 OR X except to indicate whether the child has had chickenpox. If you do not have an immunization record for this child contact your doctor or local public health department to obtain the records. TYPE OF VACCINE First Dose Second Dose Third Dose Fourth Dose Fifth Dose Month/Day/Year Diphtheria-Tetanus-Pertussis Specify DTP DTaP or DT Polio Hib Haemophilus Influenzae Type B Pneumococcal Conjugate Vaccine PCV Hepatitis B Measles-Mumps-Rubella MMR Varicella chickenpox vaccine Vaccine is required only if the child has not had chickenpox disease.