DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-04020L (Rev. 6/2020)
STATE OF WISCONSIN
Wis. Stat. §§ 252.04 and 120.12 (16)
STUDENT IMMUNIZATION RECORD
INSTRU
CTIONS TO PARENT: COMPLETE AND RETURN TO SCHOOL WITHIN 30 DAYS AFTER ADMISSION. State law requires all public and private
school students to present written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific
requirements are available from schools and local health departments. These requirements can only be waived if a properly signed health, religious or personal
conviction waiver is filed with the school. The purpose of this form is to measure compliance with the law and will be used for that purpose only. If you have
questions regarding immunizations, or how to complete this form, contact your child’s school or local health department.
Step 1 PERSONAL DATA PLEASE PRINT
Student’s Name
Birthdate (MM/DD/YYYY) Gender School Grade School Year
Name of Parent/Guardian/Legal Custodian Address (Street, City, State, Zip) Telephone Number
Step 2 IMMUNIZATION HISTORY
List the MONT
H, DAY, AND YEAR your child received each of the following immunizations. DO NOT USE A () OR (X) except to answer the
question about chickenpox, Tdap, or Td. If you do not have an immunization record for this student at home, contact your doctor or public health
department to obtain it.
TYPE OF VACCINE*
FIRST DOSE
MM/DD/YYYY
SECOND DOSE
MM/DD/YYYY
THIRD DOSE
MM/DD/YYYY
FOURTH DOSE
MM/DD/YYYY
FIFTH DOSE
MM/DD/YYYY
DTaP/DTP/DT/Td (Diphtheria, Tetanus,
Pertussis)
Adolescent booster (Check appropriate box)
Tdap Td
Polio
Hepati
tis B
MMR (Measles, Mumps, Rubella)
Varicella (Chickenpox) Vaccine
Vaccine is required only if your child has not had
chickenpox disease. See below:
Has your child had Varicella (chickenpox) disease? Check the
appropriate box and provide the year if known:
YES Year (Vaccine not required)
NO or Unsure (Vaccine required)
Has your child had a blood test (titer) that shows immunity (had disease or
previous vaccina
tion) to any of the following? (Check all that apply)
Varicella Measles Mumps Rubella Hepatitis B
If YES, provide laboratory report(s)
Step 3 REQUIREMENTS
Refer to the age/grade level requirements for the current school year to determine if this student meets the requirements.
Step 4 COMPLIANCE DATA
STUDENT MEETS ALL REQUIREMENTS
Sign at Step 5 and return this form to school.
Or
STUDENT DOES NOT MEET ALL REQUIREMENTS
Check the appropriate box below, sign at Step 5, and return this form to school. PLEASE NOTE THAT INCOMPLETELY IMMUNIZED STUDENTS
MAY BE EXCLUDED FROM SCHOOL IF AN OUTBREAK OF ONE OF THESE DISEASES OCCURS.
Although my child has NOT received ALL the required doses of vaccine, the FIRST DOSE(S) has/have been received. I understand that the
SECOND DOSE(S) must be received by the 90th school day after admission to school this year, and that the THIRD DOSE(S) and FOURTH
DOSE(S) if required must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in
writing each time my child receives a dose of required vaccine.
NOTE: Failure to stay on schedule may result in exclusion from school, court action and/or forfeiture penalty.
WAIVERS (List in Step 2 above, the date(s) of any immunizations your child has already received)
For health reasons this student should not receive the following immunizations _________________________________________
_________________________________________________________________________ ______________________________________
SIGNATURE - Physician Date Signed
For religious reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)
DTaP/DTP/DT/Td Tdap, Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella
For personal conviction reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)
DTaP/DTP/DT/Td Tdap Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella
Step 5 SIGNATURE
This form is complete and accurat
e to the best of my knowledge. Check one: (I do
I do not ) give permission to share my child’s current
immunization records and as they are updated in the future with the Wisconsin Immunization Registry (WIR). I understand that I may revoke this
consent at any time by sending written notification to the school district. Following the date of revocation, the school district will provide no new
records or updates to the WIR.
________________________________________________________________________ ________________________________________
SIGNATURE - Parent/Guardian/Legal Custodian or Adult Student Date Signed
