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Get Washington State Immunization Exemption Form 2021-2024

Certificate of Immunization Status CIS DOH 348-013 January 2015 Office Use Only Reviewed by Date Signed Cert. Documentation of Disease Immunity laboratory evidence of immunity titer to the diseases marked. Signed lab report s MUST also be attached. Diphtheria Hepatitis A Hib Measles Mumps Polio Rubella Tetanus Varicella Other Instructions for completing the Certificate of Immunization Status CIS printing it from the Immunization 1 To print with information filled in First ask if your healthcare provider s office puts vaccination history into the WA Immunization Be sure to review all the information sign and date the CIS and return it to school or child care. Form is correct and verifiable. Required for Child Care/Preschool Only Recommended but not required Parent/Guardian Signature Required Date Parent/Guardian Signature Required Vaccine Dose Month Day Year Hepatitis B Hep B or Hep B - 2 dose alternate schedule for teens Rotavirus RV1 RV5 Diphtheria Tetanus Pertussis DTaP DTP DT Tetanus Diphtheria Pertussis Tdap Haemophilus influenzae type b Hib Influenza flu most recent Pneumococcal PCV PPSV Polio IPV OPV Measles Mumps Rubella MMR Varicella chickenpox Human Papillomavirus HPV does not print from the IIS write dates in by hand Meningococcal MCV MPSV If the child named on this CIS had chickenpox disease and not the vaccine disease history must be verified. Mark option 1 2 OR 3 below see 5 on back 1 Chickenpox disease verified by printout from the Immunization Information System IIS Must be marked by printout not by hand to be valid. provider HCP If you choose this box mark 2A OR 2B below. of Exemption on file Yes No Please print* See back for instructions on how to fill out this form or get it printed from the Immunization Information System* Child s Last Name First Name Middle Initial Birthdate mm/dd/yyyy Sex I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my I certify that the information provided on this Symbols below Required for School and Child Care/Preschool child s school record. 2A Signed note from HCP attached OR 2B HCP sign here and print name below Licensed healthcare provider signature MD DO ND PA ARNP Printed Name from the Immunization Information System If the child can show immunity by blood test titer and hasn t had the vaccine ask your HCP to fill in this box. If your provider s office does not use the IIS ask for a copy of your child s vaccine record so you can fill it in by hand using steps 2-7 below EXAMPLE 2 To fill in by hand Print your child s name birthdate sex and your own name in the top box. 3 Write each vaccine your child received under the correct disease. Write the vaccine type under the Vaccine column and the date each dose was received in the Month Day and Year columns as DTaP mm/dd/yyyy. For example if DTaP was received Jan 12 March 20 June 1 11 fill in as shown here 4 If your child receives a combination vaccine one shot that protects against several diseases use the Reference Guide below to record each vaccine correctly.

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