COLORADO LAW REQUIRES THIS FORM BE COMPLETED AND PROVIDED TO THE SCHOOL Name_________________________________________________________ Date of Birth________________________ Parent/Guardian___________________________________________________________________________________
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT-CERTIFICATE OF IMMUNIZATION
VACCINE		Enter date each immunization was given.
DTP	Diphtheria-Tetanus- Pertussis
Td/DT	Tetanus-Diphtheria
OVP/IPV	Polio
Hib	Haemophilus Influenzae Type B			One dose must be on or after the first birthday
Measles	Measles		The first MMR must have been given on or after the first birthday. Written evidence of laboratory tests showing immunity to hepatitis b, measles, mumps, and rubella is acceptable. Attach written proof to this Certificate, or record test results and dates in the boxes at left.
Mumps	Mumps
Rubella	Rubella
HB	Hepatitis B
To the best of my knowledge, the person named above has received the above immunizations. DO NOT SIGN UNLESS MINIMUM IMMUNIZATION REQUIREMENTS ARE MET Signed_____________________________________________ Title____________________________ Date__________ (Physician, nurse, or school health authority)

Name______________________________________ Date of Birth__________________________________	MINIMUM IMMUNIZATION REQUIREMENTS (Your doctor or clinic may recommend additional doses)
	Preschool Grades K-6 Grades 7-12 College Vaccine (15mo-4yrs) (5-11yrs) (12-18yrs) DTP/Td/DT 3 4 4 Polio 2 3 3 Measles* 1 1 2 2 Mumps* 1 1 2 2 Rubella* 1 1 2 2 Hib** 1 Hepatitis B*** 3 3 3 Any student starting or completing the vaccine series within 6 months of first enrollment in a Colorado school may be certified with: Preschool Grades K-6 Grades 7-12 Vaccine (15mo-4yrs) (5-11yrs) (12-18yrs) DTP/ /DT OR 3 3 Td (AGE 7+) 2 2 Polio 2 2 2 Measles* 1 1 2 Mumps* 1 1 2 Rubella* 1 1 2 Hib** 1 Hepatitis B*** 3 3 3 *Measles, mumps and rubella vaccines must have been administered on or after the first birthday to be acceptable for certification. Seventh graders and college students who were born since January 1, 1957 must have had two measles, two mumps, and two rubella doses, administered at least thirty calendar days apart. If the student received a second measles dose prior to July 1, 1992, the second rubella and mumps doses are not required. By July 1, 1997, all students in grades 7-12 must comply. **One dose of Hib vaccine must have been administered at age 12 months or older. Children age 5 and older are exempt from the Hib requirement. *** Hepatitis B vaccine must be administered such that dose 2 is given not less than 30 calendar days after dose 1and dose 3 is administered not less than 60 calendar days after dose 2. In-process students are not in compliance who do not receive dose 3 within 150 calendar days after dose 2. By July 1, 2000 all students in grades K-3 & 7-10 must comply. By July 1, 2001 all students in grades K-4 & 7-11 must comply. By July 1, 2002, all students in grades K-5 & 7-12 must comply. By July 1, 2003 all students in grades K-12 must comply. 09/96
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS WILL BE SUBJECT TO EXCLUSION FROM SCHOOL AND QUARANTINE.
MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health, or is medically contraindicated due to other medical conditions. Signed__________________________________Date____________ (Physician)
RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself adheres to a religious belief opposed to immunizations. Signed__________________________________Date____________ (Parent, guardian, emancipated student/consenting minor)
PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself adheres to a personal belief opposed to immunizations. Signed___________________________________Date___________ (Parent, guardian, emancipated student/consenting minor)