The Oregon 53 05A form is a critical document known as the Certificate of Immunization Status, which is required for children attending school, preschool, child care, or home day care in Oregon. This form ensures that proof of immunization or an exemption is documented, safeguarding the health of all children in educational settings. Parents or guardians must accurately complete the form, providing essential information about their child's immunization history.
The Oregon 53 05A form, known as the Certificate of Immunization Status, plays a crucial role in ensuring that children are properly vaccinated before attending school, preschool, child care, or home day care. This form is mandated by Oregon law, which requires proof of immunization or a signed exemption. Parents or guardians must provide detailed information about their child's immunization history, including the names and birth dates, as well as the specific vaccines received and their corresponding dates. The form also accommodates exemptions, whether medical or nonmedical, and outlines the necessary documentation to support these requests. In addition to required vaccines, the form includes a section for recommended vaccines, which, while not mandatory, are generally advised for children's health. The Oregon Health Authority collects this information to maintain public health standards and may share it with local health departments as needed. Accuracy is vital, as the parent or guardian must certify the information provided. Completing both sides of the form is essential for compliance and clarity.
Oregon Certi! cate of Immunization Status
Oregon Health Authority, Immunization Program
Oregon law requires proof of immunization be provided or an exemption be signed prior to a child’s attendance at school, preschool, child care or home day care. This information is being collected on behalf of the Oregon Health Authority, Immunization Program and may be released to the Authority or the local public health department by the school or children’s facility upon request of the Authority. Please list immunizations in the order they were received.
Child’s Last Name
First
Middle Initial
Birthdate
Apellido
Primer Nombre
Segundo Nombre
Fecha de Nacimiento
Mailing Address
City
State
Zip Code
Dirección
Ciudad
Estado
Codigo Postal
Parents’ or Guardians’ Names
Home Telephone Number
Nombre de los padres o guardian
Número de Teléfono
Vaccines
Dose 1
Dose 2
Dose 3
Dose 4
Dose 5
Diphtheria/Tetanus/Pertussis
(mm/dd/yy)
(DTaP, Tdap, Td)
Booster Dose Tdap
Polio (IPV or OPV)
Varicella (Chickenpox) [VZV or VAR]
o
Check here if child has had chickenpox
disease ____________ (mm/dd/yy)
Measles/Mumps/Rubella (MMR)
or
Measles vaccine only
Mumps vaccine only
Rubella vaccine only
Hepatitis B (Hep B)
Hepatitis A (Hep A)
Haemophilus In! uenzae Type B (Hib) (Only children less than 5 years)
I certify that the above information is an accurate record of this child’s immunization history.
for all
Complete
Up-to- date
Medical
medical
Non
Signature*
Date
Update Signature
*Parent, guardian, student at least 15 years of age, medical provider or county health department staff person may sign to verify vaccinations received.
For school/facility use only
School/facility Name
Student ID Number
Grade
Continued On Reverse Side
Oregon Certificate of Immunization Status, Page 2
Child's Last Name
�
Recommended Vaccines
Pneumococcal (PCV)
=
...�
(Only in children less than 5 years)
"CS
Meningococcal (MCV4, MPSV4)
Human Papilloma Virus (HPV)
e
(9 years or older)
Influenza (Flu)
�Other Vaccine
�Please specify:
Other Vaccine Please specify:
For medical exemptions:
Please submit a letter signed by a licensed physician stating:
•Child's name
•Birth date
•Medical condition that contraindicates vaccine
•List of vaccines contraindicated
•Approximate time until condition resolves, if applicable
•Physician's signature and date
•Physician's contact information, including
phone number
For Immunity Documentation (history ofdisease or positive titer): Please submit a letter signed by a licensed physician stating:
•Child's name and birth date
•Diagnosis or lab report
Dose2
Dose3
Dose4
Doses
Nonmedical Exemption:
I have received information regarding the benefits and risks of immunizations. I understand that my child may be excluded from school or child care attendance ifthere is a case ofdisease that could be prevented by vaccine. I have attached the required document from (check one):
A health care practitioner
The vaccine educational module approved by the Oregon Health Authority
I understand that I may decline one or more vaccinations for my child and request that my
child be exempted from the following required immunizations (check all that apply):
Diphtheria/ Tetanus/Pertussis
Hepatitis B
Polio
Hepatitis A
Varicella
Hib
Measles/Mumps/Rubella
Signature of Parent or Guardian
Optional:
ORS 433.267 states that this document may include the reason for declining the immunization. Immunization is being declined because of:
Religious belief
Philosophical belief
Other
I certify that the above information is an accurate record of this child's immunization history and exemption status.
Signature
53-05A (01/2019)
Instructions for completing the
Certificate of Immunization Status
Contact information:
Complete information for your child including full name, birthdate, current mailing address, parentsÕ or guardiansÕ names and home telephone number. This information will be used to contact you if there are questions about your childÕs immunization history.
Required vaccines (Front):
Fill in the month/day/year that your child received each dose of vaccine. Doses must be listed in the order received. The shaded boxes on the form indicate doses that are not routinely given, however if your child received them, please write the date in the shaded box. Check with your childÕs school or daycare to find out which vaccines are required for your childÕs age or grade.
Recommended vaccines (Back):
These doses are not required by law, however these vaccines are recommended and most children receive them. Fill in the month/day/year that your child received each dose of vaccine. Doses should be listed in the order received. The shaded boxes on the form indicate doses that are not routinely given, however if your child received them, please write the date in the shaded box.
Signature:
The parent or guardian signature is a sworn statement that the childÕs record is accurate. The signature of a physician or local health department is not required but it is acceptable. Every time
you add on to your child’s information you need to resign the form.
REMEMBER TO COMPLETE BOTH SIDES OF FORM
Exemptions:
Oregon allows medical and nonmedical exemptions.
For a nonmedical exemption, check the appropriate box and submit one of the following required documents:
1.A certificate signed by a health care practitioner verifying discussion of the benefits and risks of immunization, or
2.A certificate of completion of the vaccine educational module about the benefits and risks of
immunization.
Indicate which vaccines you are exempting your child from by checking the boxes. Sign and date on the indicated line.
For a medical exemption or proof of immunity, submit a letter from your childÕs physician to the school or child care.
Instrucciones para llenar el
Certificado de Estado de Vacunación
Informaci—n de contacto:
DŽ la siguiente informaci—n sobre su hijo: nombre completo, fecha de nacimiento, direcci—n postal actual, nombres y nœmeros de telŽfono de los padres o tutores. Usaremos esta informaci—n para comunicarnos con usted si hay preguntas sobre los datos de vacunaci—n de su hijo.
Vacunas requeridas (adelante):
Escriba el mes/d’a/a–o en que su hijo recibi— cada dosis de vacuna. Las dosis se deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario indican las dosis que no se dan rutinariamente. Sin embargo, si su hijo las recibi—, escriba la fecha en el casillero sombreado. Averiguar con la escuela o guarder’a cuales son las vacunas requeridas para la edad y grado escolar de su ni–o.
Vacunas recomendadas (atr‡s):
Estas dosis no son obligatorias por ley, pero son recomendadas y la mayor’a de los ni–os las reciben. Escriba el mes/d’a/a–o en que su hijo recibi— cada dosis de vacuna. Las dosis se deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario indican las dosis que no se dan rutinariamente. Sin embaro, si su hijo las recibi—, escriba la fecha en el casillero sombreado.
Firma:
La firma del padre, madre o tutor es una declaraci—n jurada de que la historia de vacunas del ni–o esta correcta. La firma del mŽdico o del departamento de salud local no son requieridas, pero son aceptable. Cada vez que agregue datos a la información sobre su hijo debe
volver a firmar el formulario.
RECUERDE LLENAR AMBOS LADOS DEL FORMULARIO
Excepciones:
Oregon permite excepciones mŽdicas y no mŽdicas.
Para una excepci—n no mŽdica, marque la casilla adecuada y presente uno de los siguientes documentos requeridos:
1.Un certificado firmado por un proveedor de atenci—n de salud verificando la discusi—n de los beneficios y riesgos de la vacunaci—n, o
2.Un certificado de terminaci—n del m—dulo educativo de la vacuna sobre los beneficios y
riesgos de la vacunaci—n.
Indique para cu‡les vacunas quiere que su hijo(a) sea exento(a) al marcar las casillas. Firme y feche la l’nea indicada.
Para una excepci—n mŽdica o un comprobante de inmunidad, presente una carta del doctor de su hijo(a) a la escuela o cuidado infantil.
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