Universal Health Certificate - District of Columbia

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Student’s Name: __________________________ __/_________________________/________________ Date of Birth:_____/_____/________
Last First Middle Mo. /Day/ Yr.
Sex:
Male Female School or Child Care Facility:______________________________________________________________
Section 1: Immunization: Please fill in or attach equivalent copy with provider signature and date.
IMMUNIZATIONS RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
Diphtheria,Tetanus, Pertussis (DTP,DTaP)
1 2 3 4 5
DT (<7 yrs.)/ Td (>7 yrs.)
1 2 3 4 5
Tdap Booster
1
Haemophilus influenza Type b (Hib )
1 2 3 4
Hepatitis B (HepB)
1 2 3 4
Polio (IPV, OPV)
1 2 3 4
Measles, Mumps, Rubella (MMR)
1 2
Measles
1 2
Mumps
1 2
Rubella
1 2
Varicella
1 2
Chicken Po x Disea s e History: Yes
When: Month____________ Year___________
Verified by:___________________________________________ (Health Care Provider)
Name & Title
Pneumococcal Conjugate
1 2 3 4
Hepatitis A (HepA) (Born on or after 01/01/2005)
1 2
Meningococcal Vaccine
1
Human Papillomavirus (HPV)
1 2 3
Influenza (Recommended)
1 2 3 4 5 6 7
Rotavirus (Recommended)
1 2 3
Other
_______________________________________________ ______ _________________________________ __________
Signature of Medical Provider Print Name or Stamp Date
Section 2: MEDICAL EXEMPTION. For Health Care Provider Use Only.
I certify that the above student has a valid medical contraindication to being immunized at the time against: (check all that apply)
Diphtheria: (__) Tetanus: (__) Pertussis: (__) Hib: (__) HepB: (__) Polio: (__) Measles: (__) Mumps: (__) Rubella: (__) Varicella: (__) Pneumococcal: (__)
HepA: (__) Meningococcal: (__) HPV: (__)
Reason:________________________________________________________________________________________________________________________
This is a permanent condition (___) or temporary condition (___) until ____/____/____.
_______________________________________________ ___________________ ____________________ __________
Signature of Medical Provider Print Name or Stamp Date
Section 3: Alternative Proof of Immuni ty. To be completed by Health Care Provider or Health Official.
I certify that the student named above has laboratory evidence of immunity: (Check all that apply & attach a copy of titer results)
Diphtheria: (__) Tetanus: (__) Pertussis: (__) Hib: (__) HepB: (__) Polio: (__) Measles: (__) Mumps: (__) Rubella: (__) Varicella: (__) Pneumococcal: (__)
HepA: (__) Meningococcal: (__) HPV: (__)
_______________________________________________ _________________ ______________________ _____ _____
Signature of Medical Provider Print Name or Stamp Date
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