Fillable CERTIFICATE OF IMMUNIZATION (State of Tennessee)

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CERTIFICATE OF IMMUNIZATION (State of Tennessee)

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CERTIFICATE OF IMMUNIZATION
Child's Name (Last name, first name, middle) Birthdate (mm/dd/yy)
Parent/Guardian Name (Last name, first name, middle)
Phone (please include area code xxx-xxx-xxxx)
Address
City State Zip Code
Section 1a. Religious Exemption
Check here if religious exemption to immunization selected by
parent/guardian
1b. Health Examination Documentation (if required)
This child has been examined:
MM / DD / YY
Certified by (Signature/Stamp)
1c. Check if needed
Dental Screening
Vision Screening
Unless specifically exempted by law, Tennessee law requires a certificate on file for each child in attendance in any school or child care facility in Tennessee. Detailed
instructions for this form and explanation of requirements are in "TDH Summary of Immunization Rules- Certificate Instructions" at the Tennessee Department of Health
website (https://www.tn.gov/health/cedep/immunization-program/ip/immunization-requirements.html) and on the Tennessee Immunization Information System (tennesseeiis.gov).
VACCINE
DATE
MM/DD/YY
DATE
MM/DD/YY
DATE
MM/DD/YY
DATE
MM/DD/YY
DATE
MM/DD/YY
DATE
MM/DD/YY
Diagnosed (X)
+Serology (X)
History (X)
Medical
Exemption (X)
Section 2a. Required Vaccines for School or Child Care Attendance (Dates Required)
Hib
Child Care Only (<5 y
ears)
Pneumococcal (PCV)
Child Care Only (<5 years)
DTP, DTap, DT, Td
Poliomyelitis
Hepatitis B
Check here if 11-15 years
2-dose schedule used
Hepatitis A
Child Care Effective 7/2010
Kindergarten Effective 7/2011
Measles
Mumps
Rubella
Varicella
Tdap Booster
7th Grade Entry Only
Section 2b. Recommended Vaccines (Documentation Optional)
Rotavirus
Influenza
Meningococcal ACWY
HPV
Section 3. Provider Assessment (select one*, not valid if blank)
Temporary Certificate - ExpiresA) MM / DD / YYYY
Expiration date one month after date next catch-up immunization is due.
B) Up to Date for Child Care Entry and <18 Months of Age
Only if requirements incomplete, but up to date for age. Expires at 19 months of age.
C) Complete for Child Care / Pre-School*
Fulfills all requirements for child care / pre-school or pre-K under 5 years of age.
D) Complete K-6th Grade*
Fulfills requirements, Kindergarten through 6th grade.
E) Complete 7th Grade or Higher
Fulfills requirements, 7th grade or higher
*If age 4 years and fulfills requirements for Pre-School and Kingergarten, check BOTH Boxes C and D.
Section 4. (Required) Name, Address, Phone of Qualified Provider
(MD, DO, PA, Advanced Practice Nurse or Health Department):
MM | DD | YYYY
Certified by (Signature/Stamp) or TennIIS Date of Issue
PH-4103 (Rev. 1/18) RDA-N/A
SAMPLE
**VOID**
[1] Hib HbOC or 1 2 3 4
[1] Hib PRP-T or
1 2 3 4
[1] Hib PRP-OMP
1 2 3
[2] PCV
1 2 3 4
[3] DTP, DTaP, DT 1 2 3 5
[4] Polio 1 2 3 4
[5] Hepatitis B 1 2 3
[6] Hepatitis A 2
[7] MMR 1 2
[8] Varicella 1 2
[9] Tdap
[1] Hib (Primary Series)
HbOC & PRP-T
PRP-OMP
[2] PCV
[3] DTP/DTaP (DT)
[4] Polio
[5] Hepatitis B
[6] Hepatitis A
[7] MMR
[8] Varicella
[9] Tdap
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
PH-4103 (Rev. 1/18) RDA-N/A
*These requirements were established in accordance with the current Recommended
Childhood and Catch-up Immunization Schedules, United States
(cdc.gov/vaccines/schedules/hcp/child-adolescent.html
). Tennessee requirements for
Kindergarten (5 years) include doses indicated for 4-6 years.
**Certificates marked "Up to Date for Child Care Entry and <18 Months of Age" expire
at 19 months of age. Parent/Guardian must provide an up-to-date certificate indicating
"Complete for Child Care/ Pre-school" by or before 19 months of age.
****Children who are behind schedule may attend while in the process of completing
the requirements with minimum intervals as indicated below.
***For children starting immunizations at age 7 years or older, refer to the CDC/ACIP
catch-up schedule available at:
https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html
Vaccine Requirements for Attending Child Care Facilities, Pre-Schools and Schools in Tennessee*
The number of doses in the PCV series depends on age at 1st dose. Children who receive 3 doses before 12 months of age require a 4th dose after the 1st birthday. One dose is required after 12 months of age for all children
aged 24-59 months with any incomplete schedule. The final dose should be given at least 8 weeks after the previous dose and not before 12 months of age. Consult the Catch Up schedule for additional guidance.
Footnotes
Recommended Schedule of Required Doses for Attendance in Child Care / Pre-School / Pre-K and School
For Children Who Started Immunizations Before Age 7 Years***
Minimum interval
from dose 2 to 3
28 Days
12-15
Month of
Age
6 weeks
28 Days
28 Days
N/A
28 Days
28 Days
See Footnote [1]
6 weeks
6 weeks
See Footnote [2]
Minimum interval
from dose 3 to 4
See Footnote [1]
5 or 4 (See Footnote [3])
5, 4 or 3 (See Footnote [4])
3 (See Footnote [5])
Minimum interval
from dose 1 to 2
N/A
28 Days
6
Months
of Age
4
Months
of Age
2
Months
of Age
Required Vaccines with
footnote numbers in [ ]
2 (See Footnote [7])
2 (See Footnote [8])
4
1
N/A for school (See Footnote [2])
Total Doses Required**** For
Assessment of Complete For School
Attendance on Immunization Certificate
N/A for school (See Footnote [1])
N/A for school (See Footnote [1])
N/A for school (See Footnote [1])
4-6 Yrs.*
(School
Entry)
16-18**
Month
of Age
A single dose of Tdap is required for 7th grade entry. Tdap meets the requirement if given any time after the 7th birthday. If Tdap is needed, it may be given regardless of interval since last Td.
The MMR requirement is 2 doses of measles vaccine, 2 doses of mumps vaccine and 2 doses of rubella vaccine, in combination or separately. Dose 2 of MMR is routinely given at 4-6 years, but may be given as soon as 28
days after dose 1.
28 Days
28 Days
28 Days
birth
12 months
12 months
See Footnote [9]
6 weeks
One dose of hepatitis A vaccine is required for all children in child care aged 18 months or greater. The recommended schedule is for two doses, 6 to 18 months apart, beginning at one year of age. Proof of two doses, at least
6 months apart, is required for Kindergarten entry. Hepatitis A vaccine is not required for entry in older school grades.
The varicella requirement is for 2 doses of varicella vaccine or history of disease for all students entering Kindergarten, and new entrants into a Tennessee school in any other grade. The second dose is recommended 3 or
more months after the first dose, routinely at age 4-6 years; in keeping with CDC guidance, the second dose is acceptable if given at least 4 weeks after the first dose.
6 months
N/A
N/A
See Footnote [4]
Do not restart any series, no matter how long since the previous dose. Doses given up
to 4 days before the minimum age or the minimum interval may be counted as valid.
Two different live vaccines must be given on the same day or spaced at least 28 days
apart. The 4-day "grace period" does not apply to the 28-day interval between live
vaccines not administered at the same visit.
For purposes of vaccine spacing: For intervals less than 4 months, 28 days = one
"month" (1 month=4 weeks=28 days). For intervals of 4 months or longer, a "month" is
a "calendar month." Ex: Six months from January 1 is July 1.
The 3rd valid dose of hepatitis B vaccine must be at least 4 months after dose 1 and 2 months after dose 2 and not before 24 weeks of age. If the 3rd dose given is not valid for all criteria, a 4th dose is necessary.
Minimum Ages For Initial Immunization And Minimum Intervals Between Doses
28 Days
2 (See Footnote [6])
The number of doses of Hib depends on age at 1st dose and brand of vaccine given. The last dose in the series necessary to meet requirements, whether 3rd or 4th, should be given at least 2 months after the previous dose
and not before 12 months of age. One dose is sufficient to meet requirements if it is given at age 15 months or later. Hib is required for children younger than 5 years attending child care facilities. Hib is not required for
kindergarten or higher grades and is not indicated for children who have reached the 5th birthday. If given on schedule, PRP-T and HbOC have a 3 dose primary series and a booster after age 12 months. PRP-OMP has a 2-
dose primary schedule and a booster after 12 months. Providers are responsible for verifying that the child meets the appropriate schedule for the brand used.
1 (7th grade only)
Minimum Age For
First Dose
12 months
6 months
28 Days
3 months [8]
6 weeks
The minimum interval between the 4th and 5th doses is 6 months: dose 4 may be given as early as 12 months, but typically is given at age 15-18 months. One dose of DTP/DTaP/DT must be on or after the 4th birthday. If the
4th dose was on or after the 4th birthday, the 5th dose is not needed. The 4th dose should be administered a minimum of 6 months after the 3rd dose. However, the 4th dose does not need to be repeated if administered ≥ 4
months after dose 3. Total doses of diphtheria and tetanus toxoids should not exceed 6 before the 7th birthday.
The final dose of the polio vaccine series must be given on or after the 4th birthday and at least 6 months after the previous dose. If 4 doses are administered before the 4th birthday, a 5th dose should be given on or after the
4th birthday. If the 3rd dose of an all IPV or all OPV series is given on or after the 4th birthday and at least 6 months after the 2nd dose, a 4th dose is not needed.
See Footnote [5]
N/A
N/A
Vaccine
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CERTIFICATE OF IMMUNIZATION (State of Tennessee)

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Completed 17 August 2021

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