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Get KS Certificate of Immunization (KCI) 2013

Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.) Student Name: Address: Parent or Guardian Name: Phone: Birthdate (MM/DD/YYYY): 1st DT DTaP Td Tdap (Diphtheria, Tetanus, Pertussis) Required for 2nd DT DTaP Td Tdap 3rd DT DTaP Td Tdap 4th DT DTaP Td Tdap 5th DT DTaP Td Tdap (Hepatitis B) Required for school entry. Varicella Hx of Disease: Physician Signature: (Chickenpox) Required for school entry. 2 doses grades K-4 & 7-9. One dose Grades 5-6 and 10-12 for .

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