Fillable Oregon Health Authority, Immunization Program Oregon Certi cate (Oregon)

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Oregon Health Authority, Immunization Program Oregon Certi cate (Oregon)

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The Oregon Health Authority, Immunization Program Oregon Certi cate (Oregon) form is 2 pages long and contains:

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  • 13 check-boxes
  • 89 other fields

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File type: PDF

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Oregon law requires proof of immunization be provided or an exemption be signed prior to a
child’s attendance at school, preschool, child care or home day care. This information is being
collected on behalf of the Oregon Health Authority, Immunization Program and may be released
to the
Authority or the local public health department by the school or children’s facility upon
request of the Authority. Please list immunizations in the order they were received.
Child’s Last Name
Apellido
First
Primer Nombre
Middle Initial
Segundo Nombre
Birthdate
Fecha de Nacimiento
Mailing Address
Dirección
City
Ciudad
State
Estado
Zip Code
Codigo Postal
Parents’
or Guardians’ Names
Nombre de los padres o guardian
Home Telephone Number
Número de Teléfono
Continued On Reverse Side
I certify that the above information is an accurate record of this child’s immunization history.
Signature*
Date
Update Signature
Date
Update Signature
Date
Update Signature
Date
*Parent, guardian, student at least 15 years of age, medical p
rovider or
county health department staff p
erson may sign to verify vaccinations
received.
Oregon Certifi cate of Immunization Status
Oregon Health Authority, Immunization Program
Vaccines Dose 1 Dose 2 Dose 3 Dose 4 Dose 5
Diphtheria/Tetanus/Pertussis
(DTaP, Tdap, Td)
(mm/dd/yy) (mm/dd/yy)
(mm/dd/yy) (mm/dd/yy) (mm/dd/yy)
Booster Dose Tdap
Polio (IPV or OPV)
Varicella (Chickenpox) [VZV or VAR]
o Check here if child has had chickenpox
disease ____________ (mm/dd/yy)
Measles/Mumps/Rubella (MMR)
or
Measles vaccine only
Mumps vaccine only
Rubella vaccine only
Hepatitis B (Hep B)
Hepatitis A (Hep A)
Haemophilus Infl uenzae Type B (Hib)
(Only children less than 5 years)
For school/facility use only
School/facility Name
Student ID Number
Grade
Complete
for all
Up-to-
date
Medical
Non
medical
Oregon Certicate of Immunization Status, Page 2
Oregon Health Authority, Immunization Program
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
Apellido Primer mbre

Sendo Nombre Fecha de Nacimiento
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
For medical exemptions:

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

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 
  
Nonmedical Exemption:
 

 



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
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

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
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


Optional:

 
    
I certi that the above inrmation is an accurate record of this child's immunization history and exemption stas.
Signare
Date
Update Signare
Date
Update Signare
Date
Update Signare
Date

Instructions for completing the
Certificate of Immunization Status
Contact information:
Complete information for your child including full name, birthdate, current mailing address, parents’ or
guardians’ names and home telephone number. This information will be used to contact you if there
are questions about your child’s immunization history.
Required vaccines (Front):
Fill in the month/day/year that your child received each dose of vaccine. Doses must be listed in the
order received. The shaded boxes on the form indicate doses that are not routinely given, however if
your child received them, please write the date in the shaded box. Check with your child’s school or
daycare to find out which vaccines are required for your child’s age or grade.
Recommended vaccines (Back):
These doses are not required by law, however these vaccines are recommended and most children
receive them. Fill in the month/day/year that your child received each dose of vaccine. Doses should
be listed in the order received. The shaded boxes on the form indicate doses that are not routinely
given, however if your child received them, please write the date in the shaded box.
Signature:
The parent or guardian signature is a sworn statement that the child’s record is accurate. The
signature of a physician or local health department is not required but it is acceptable. Every time
you add on to your child’s information you need to resign the form.
REMEMBER TO COMPLETE BOTH SIDES OF FORM
Exemptions:
Oregon allows medical and nonmedical exemptions.
For a nonmedical exemption, check the appropriate box and submit one of the following required
documents:
1. A certificate signed by a health care practitioner verifying discussion of the benefits and risks of
immunization, or
2. A certificate of completion of the vaccine educational module about the benefits and risks of
immunization.
Indicate which vaccines you are exempting your child from by checking the boxes. Sign and date on
the indicated line.
For a medical exemption or proof of immunity, submit a letter from your child’s physician to the school
or child care.
Instrucciones para llenar el
Certificado de Estado de Vacunación
Información de contacto:
Dé la siguiente información sobre su hijo: nombre completo, fecha de nacimiento, dirección
postal actual, nombres y números de teléfono de los padres o tutores. Usaremos esta
información para comunicarnos con usted si hay preguntas sobre los datos de vacunación de
su hijo.
Vacunas requeridas (adelante):
Escriba el mes/día/año en que su hijo recibió cada dosis de vacuna. Las dosis se deben
enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario
indican las dosis que no se dan rutinariamente. Sin embargo, si su hijo las recibió, escriba la
fecha en el casillero sombreado. Averiguar con la escuela o guardería cuales son las vacunas
requeridas para la edad y grado escolar de su niño.
Vacunas recomendadas (atrás):
Estas dosis no son obligatorias por ley, pero son recomendadas y la mayoría de los niños las
reciben. Escriba el mes/día/año en que su hijo recibió cada dosis de vacuna. Las dosis se
deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario
indican las dosis que no se dan rutinariamente. Sin embaro, si su hijo las recibió, escriba la
fecha en el casillero sombreado.
Firma:
La firma del padre, madre o tutor es una declaración jurada de que la historia de vacunas del
niño esta correcta. La firma del médico o del departamento de salud local no son requieridas,
pero son aceptable. Cada vez que agregue datos a la información sobre su hijo debe
volver a firmar el formulario.
RECUERDE LLENAR AMBOS LADOS DEL FORMULARIO
Excepciones:
Oregon permite excepciones médicas y no médicas.
Para una excepción no médica, marque la casilla adecuada y presente uno de los siguientes
documentos requeridos:
1. Un certificado firmado por un proveedor de atención de salud verificando la discusión de
los beneficios y riesgos de la vacunación, o
2. Un certificado de terminación del módulo educativo de la vacuna sobre los beneficios y
riesgos de la vacunación.
Indique para cuáles vacunas quiere que su hijo(a) sea exento(a) al marcar las casillas. Firme y
feche la línea indicada.
Para una excepción médica o un comprobante de inmunidad, presente una carta del doctor de
su hijo(a) a la escuela o cuidado infantil.
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Oregon Health Authority, Immunization Program Oregon Certi cate (Oregon)

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Completed 17 March 2021

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