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TENNESSEE DEPARTMENT OF HEALTH TENNESSEE SCHOOL IMMUNIZATION CERTIFICATE This form and any attachments must be filed in the child s health record. I. IDENTIFYING INFORMATION Child s Name Birth Date First Middle Last Parent/Guardian s Name Phone No* Address Street City State Zip II. REQUIRED IMMUNIZATIONS Children entering school K-12 must have the following immunizations or an appropriately documented exemption VACCINE COMMENT DTP/DTaP/DT/Td 4 or 5 A 5th dose is not required if the 4th dose is given after the 4th birthday. Only 3 doses are needed if DT or Td must be used and the first dose is given after 12 months of age. Polio 3 or 4 If the 3rd dose is given after age 4 the 4th dose is not required* If the child has received both OPV and IPV a total of 4 doses are needed regardless of age. Hepatitis B 2 or 3 Required for Kindergarten entry 3 doses and 7th grade. For adolescents a 2dose vaccine preparation is available. MMR Required on or after the 1st birthday first dose may be given no earlier than 4 days before the 1st birthday. Varicella Chickenpox DOSES For Kindergarten entry only. Required on or after the 1st birthday may be given no earlier than 4 days before the 1st birthday. Parental or physician diagnosis of chickenpox also meets requirement. CURRENT IMMUNIZATION RECORD IF COMPLETING MANUALLY RECORD THE DATE MM/DD/YY OF EACH DOSE* Vaccine Second Third Fourth Fifth Polio OPV/IPV Measles/Mumps/ Rubella MMR Or date of chickenpox disease Check here if a 2-dose hepatitis B vaccine schedule for adolescents was used IV. IMMUNIZATION CERTIFICATIONS A. Immunization This child has received the immunizations required for school attendance or has been granted a medical exemption* Medical Provider s Name Please Print B. Date Religious Exemption This child is exempt from receiving required immunizations for religious reasons. A signed statement from the parents stating under penalty of perjury that immunization conflicts with their religious tenets and practices is attached* Check here if religious exemption selected V. Health Examination Required for children initially entering Tennessee schools in grades K-12. This child has been examined* Check if needed Dental Screening PH 3722 Rev 06/06 Vision Screening RDA N/A. I. IDENTIFYING INFORMATION Child s Name Birth Date First Middle Last Parent/Guardian s Name Phone No* Address Street City State Zip II. REQUIRED IMMUNIZATIONS Children entering school K-12 must have the following immunizations or an appropriately documented exemption VACCINE COMMENT DTP/DTaP/DT/Td 4 or 5 A 5th dose is not required if the 4th dose is given after the 4th birthday. REQUIRED IMMUNIZATIONS Children entering school K-12 must have the following immunizations or an appropriately documented exemption VACCINE COMMENT DTP/DTaP/DT/Td 4 or 5 A 5th dose is not required if the 4th dose is given after the 4th birthday. Only 3 doses are needed if DT or Td must be used and the first dose is given after 12 months of age. Only 3 doses are needed if DT or Td must be used and the first dose is given after 12 months of age. Polio 3 or 4 If the 3rd dose is given after age 4 the 4th dose is not required* If the child has received both OPV and IPV a total of 4 doses are needed regardless of age.