Certificate of Immunization Status CIS DOH 348-013 January 2015 Office Use Only Reviewed by Date Signed Cert. Documentation of Disease Immunity laboratory evidence of immunity titer to the diseases marked. Signed lab report s MUST also be attached. Diphtheria Hepatitis A Hib Measles Mumps Polio Rubella Tetanus Varicella Other Instructions for completing the Certificate of Immunization Status CIS printing it from the Immunization 1 To print with information filled in First ask if your healthcare provider s office puts vaccination history into the WA Immunization Be sure to review all the information sign and date the CIS and return it to school or child care. Form is correct and verifiable. Required for Child Care/Preschool Only Recommended but not required Parent/Guardian Signature Required Date Parent/Guardian Signature Required Vaccine Dose Month Day Year Hepatitis B Hep B or Hep B - 2 dose alternate schedule for teens Rotavirus RV1 RV5 Diphtheria Tetanus Pertussis DTaP DTP DT Tetanu....
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How to use or fill out the WA DOH 348-013 online
The WA DOH 348-013, commonly known as the Certificate of Immunization Status (CIS), is a crucial document for maintaining immunization records for children in schools and childcare settings in Washington State. This guide provides step-by-step instructions to help users easily complete the form online.
Follow the steps to fill out the WA DOH 348-013 form online.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Enter your child's last name, first name, and middle initial in the designated fields. Make sure to accurately provide your child’s birthdate in the format MM/DD/YYYY.
- Provide your consent by checking the box that allows your child's school or childcare to add immunization information into the Immunization Information System.
- If applicable, check the box acknowledging your child’s conditional status when entering school or childcare, and remember to provide the required documentation within the established deadlines.
- Sign and date the form in the appropriate fields to validate that the information provided is accurate.
- Record the date of each vaccine dose your child has received in the respective columns formatted as MM/DD/YY. Use the reference guides provided in the form to ensure vaccines are recorded correctly.
- If your child has a verified history of varicella (chickenpox), ensure that this is documented by a healthcare provider and have them sign the form in the Documentation of Disease Immunity section.
- If applicable, provide proof of immunity through lab reports verifying your child’s immunity to any listed diseases, also with appropriate validation by a healthcare provider.
- Before finalizing, review all entered information for accuracy. After confirming there are no errors, save the changes, and proceed with the option to download, print, or share the completed form.
Complete the WA DOH 348-013 form online today to ensure your child's immunization records are up to date.
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