Fillable Documenting History of Illness: Varicella (Chickenpox) (Keene Independent School District)

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Documenting History of Illness: Varicella (Chickenpox) (Keene Independent School District)

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Documenting History of Illness: Varicella (Chickenpox)
This form summarizes the “Exceptions to Immunization Requirement (Verification of
Immunity/History of Illness)” incorporated in Title 25 Health Services §97.65 of the
Texas Administrative Code (TAC).
Section §97.65 of the TAC states, “A written statement from a parent (or legal guardian or
managing conservator), school nurse, or physician attesting to a child's/student’s positive history
of varicella disease (chickenpox), or of varicella immunity, is acceptable in lieu of a vaccine
record for that disease (see form at http://www.dshs.state.tx.us/immunize/docs/c-9.pdf).” School
nurses may also write a statement to record cases of chickenpox that they see. The school will
make and keep copies of any reports proving chickenpox illness or the results of any serologic
tests given as proof of immunity. The original should be given back to the parent or guardian. If
a parent or guardian cannot give the history of disease, or if serologic proof is not available, the
varicella vaccine requirement must be met.
Proof of having had chickenpox disease can be proved by:
1. Serologic blood confirmation of varicella immunity.
2. A written report from a doctor, school nurse, or the parent or guardian of the
child or student using words like:
“This is to prove that __________________________________had chickenpox on or about
(
Name of student)
_________________________ and does not need varicella vaccine.”
(month / day / year)
____________________________________
(Signature)
____________________________________
(Relationship to student)
_________________________
(Date)
Visit our website at:
www.immunizetexas.com
Texas Department of State Health Services Stock No. C-9
Immunization Unit Revised 11/2016
Documentación del historial de enfermedad: Varicela (Chickenpox)
Este formulario resume las “Excepciones al Requisito de Inmunización (Verificación de
inmunidad/Historial de la enfermedad)" incorporadas en el Título 25, Servicios de Salud,
Sección §97.65 del Código Administrativo de Texas (TAC).
La Sección §97.65 del TAC estipula: “Una declaración firmada de uno de los padres (o tutor
legal, o padre con la custodia principal), o la enfermera de la escuela o un médico, la cual dé fe
de que el niño o estudiante tiene un historial positivo de enfermedad de la varicela (chickenpox),
o tiene inmunidad a la varicela, es aceptable en lugar de un registro de la vacuna contra esta
enfermedad (vea el formulario en http://www.dshs.state.tx.us/immunize/docs/c-9.pdf).” Las
enfermeras de la escuela también pueden hacer una declaración por escrito para registrar los
casos de varicela que vean. La escuela hará y guardará copias de cualquier informe que
demuestre que se ha tenido la enfermedad de la varicela o de los resultados de cualquier
análisis serológico que se hayan entregado como prueba de inmunidad. El original debe
regresarse al padre o tutor. Si el padre o tutor no pueden proporcionar el historial de enfermedad,
o no cuentan con evidencia serológica disponible, el requisito de vacunación contra la varicela
debe cumplirse.
Se puede probar que se ha tenido la enfermedad de la varicela mediante:
1. Confirmación serológica sanguínea de inmunidad a la varicela.
2. Un informe por escrito de un médico, enfermera de la escuela, o uno de los
padres o tutor del niño o estudiante, que diga algo como lo siguiente:
“Por este medio demuestro que _________________________________________________
(Nombre del estudiante)
tuvo varicela en esta fecha o en una fecha aproximada _________________________ y no
necesita la vacuna contra la varicela.”
(mes / día / año)
_______________________________________
(Firma)
_______________________________________
(Relación con el estudiante)
_________________________
(Fecha)
Visite nuestro sitio web en:
www.immunizetexas.com
Texas Department of State Health Services Stock No. C-9
Immunization Unit Revised 11/2016
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Documenting History of Illness: Varicella (Chickenpox) (Keene Independent School District)

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Completed 31 July 2021

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