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Blank Oregon 53 05A Form

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.

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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.

Form Example

Vaccines / Vacunas
Dose 1 Dose 2 Dose 3 Dose 4 Dose 5
Dosis 1 Dosis 2 Dosis 3 Dosis 4 Dosis 5
Diphtheria/Tetanus/Pertussis
(DTaP)
Difteria/tétanos/tos ferina
(Tdap)
Polio (IPV or OPV)
Varicella (Chickenpox)
Varicela
Measles/Mumps/Rubella (MMR)
Sarampión/paperas/rubéola
Hepatitis B (Hep B)
Hepatitis A (Hep A)
Haemophilus Inuenzae Type B
Tipo B (Hib)
Oregon Certicate of Immunization Status
Certicado de estado de vacunación
Oregon law requires proof of immunization or exemption 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 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.
La ley de Oregon requiere que se entregue un comprobante de vacunación o de exención rmado antes de
que un(a) menor asista a la escuela, al preescolar, a un centro de cuidado infantil o a una guardería. Esta
información se recopila en nombre de la Autoridad de Salud de Oregon y la escuela o el centro infantil, y
puede divulgarse a la Autoridad o al departamento local de salud pública, si la Autoridad la solicita.
Child’s last name
Apellido del/de la menor
Parents’ or Guardians’ names
Nombre de los padres o tutores
First name
Phone number
Primer Nombre
Número de Teléfono
Middle name
Segundo Nombre
Birth date
Fecha de Nacimiento
Write the dates the child received the vaccines
Indique las fechas en las que el/la menor recibió las vacunas
I certify that the information on the form is an accurate record of this child’s immunizations.
Certico que la información en el formulario es un registro exacto de las vacunas de este(a) menor.
Signature*
UpdateSignature
Date
Date
Firma* X
Acualizar la rma
Fecha
*Parent, guardian, child at least 15 years of age, medical provider or county health department sta
person may sign to verify vaccinations received.
*El padre, la madre, el tutor, un estudiante de por lo menos 15 años de edad, un proveedor médico o un
miembro del personal del departamento de salud del condado puede firmar para verificar las vacunas.
53-05A (04/2025)
Fecha
Other vaccine received
Otras vacunas recibidas
Vaccine name
Nombre de la vacuna
Date
Fecha
Child’s last name
Apellido del/de la menor
First name
Primer Nombre
Middle name
Segundo Nombre
Birth date
Fecha de Nacimiento
Medical exemptions and immunity documentation
Documentación para exenciones médicas y
documentación de inmunidad.
A medical exemption requires a form completed
and signed by a licensed physician or local health
department. The form must be submitted to your
child’s school or child care. Immunity documentation
requires a proof from a blood test or documentation
from a health care practitioner or local health
department. For more information, go to www.
healthoregon.org/medicalexemptions
Una exención médica, requiere un formulario
completado y rmado por un médico u departamento
de salud local. El formulario debe entregarse a la
escuela o guardería de su hijo. La documentación
de inmunidad requiere un comprobante por análisis
de sangre o documentación de un médico u del
departamento de salud local. Para más información,
visite www.healthoregon.org/medicalexemptions
Nonmedical exemption / Exención no médica
I have received information regarding the benets and risk of immunizations. I understand my child may be
excluded from school or child care if there is a case of disease that could be prevented by vaccine.
I have attached the required document from (check one):
The vaccine module approved by the Oregon Health Authority
A health care practitioner
He recibido la información relacionada con los benecios y los riesgos de las vacunas. Entiendo que pueden
excluir a mi hijo(a) de la escuela o del centro de cuidado infantil si se presenta un caso de enfermedad que
podría prevenirse con una vacuna. Adjunto el documento requerido de parte de (marque una opción):
El módulo de vacunas aprobado por la Autoridad de Salud de Oregon
Un proveedor de atención médica
I request that my child be exempted from the following required immunizations (check all that apply):
Difteria/tétanos/tos ferina
Sarampión/paperas/rubéola
Polio Varicella /Varicela
Hepatitis B Hepatitis A
Hib
Measles/Mumps/Rubella /
Diphtheria/Tetanus/Pertussis /
Optional /Opcional
Immunizations are being declined because of:
Religious belief / Philosophical belief /Creencias losócas
OtroOther /
Solicito que se exente a mi hijo(a) de las siguientes vacunas requeridas (marque todas las opciones que
correspondan):
Date
Fecha
53-05A (04/2025)
Signature*
Firma* X
Creencias religiosas
Se están rechazando las vacunas debido a lo siguiente:
Instructions for Completing the
Certicate of Immunization Status
Contact information:
Complete information for your child including full name, birthdate, current mailing address, parents’ or
guardians’ names and phone number. This information will be used to contact you if there are questions about
your child’s immunization history.
Required vaccines (First page):
Signature:
Other vaccines received (Second page):
Exemptions:
Fill in the month/day/year that your child received each dose of vaccine. Doses must be listed in the order
received. Check with your child’s school or daycare to nd out which vaccines are required for your child’s age
or grade.
The parent or guardian signature is a sworn statement that the child’s record is accurate.
The signature of a
physician or local health department is not required but it is acceptable. People 15 years and older can sign
their own records. Every time you add on to your child’s information you need to resign the form.
For any vaccine not listed on the front, ll in the month/day/year that your child received each dose of vaccine.
Oregon allows medical and nonmedical exemptions.
For a nonmedical exemption, check the appropriate box and submit one of the following required documents:
1. A certicate signed by a health care practitioner verifying discussion of the benets and risks of
immunization, or
2. A certicate of completion of the vaccine educational module about the benets 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, submit the Oregon Medical Exemption Form signed by your child’s physician to the
school or child care.
Immunity documentation requires a proof of disease from a blood test or documentation from a health care
practitioner or local health department. Submit this documentation to the school or child care.
53-05A (04/2025)
Instrucciones para llenar el
Certicado de Estado de Vacunación
Información de contacto:
Vacunas requeridas (primera página):
Otras vacunas recibidas (segunda página):
Exenciones:
Dé la siguiente información sobre su hijo(a): nombre completo, fecha de nacimiento, nombres de los padres
o tutores. Usaremos esta información para comunicarnos con usted si hay preguntas sobre los datos de
vacunación de su hijo(a).
Escriba el mes/día/año en que su hijo(a) recibió cada dosis de vacuna. Las dosis se deben enumerar en el
orden en que fueron recibidas. Averiguar con la escuela o guardería cuales son las vacunas requeridas para la
edad y grado escolar de su niño(a).
Firma:
La firma del padre, madre o tutor, es una declaración jurada de que la historia de vacunas del niño esta
correcta. La firma del médico o del departamento de salud local no son requeridas, pero son aceptadas.
Cada vez que agregue datos a la información sobre su hijo(a) debe volver a firmar el formulario.
Por vacunas que no están mencionadas en la primera página nómbrelas en la segunda página, escriba el
mes/día/año en que su hijo(a) recibió cada dosis de vacuna.
Oregón permite exenciones médicas y no médicas.
Para una exención no médica, marque la casilla adecuada y presente uno de los siguientes documentos
requeridos:
1. Un certicado rmado por un proveedor de atención de salud vericando la discusión de los benecios
y riesgos de la vacunación, o
2. Un certicado de terminación del módulo educativo de la vacuna sobre los benecios y riesgos de la
vacunación.
Para una exención médica presente el formulario de Exención Médica de Oregon rmado por el doctor de su
hijo(a) o el departamento de salud local a la escuela o cuidado infantil.
La documentación de inmunidad requiere un comprobante de enfermedad por análisis de sangre o
documentación de un médico u del departamento de salud local. Entregue la documentación a la escuela o
guardería.
PUBLIC HEALTH DIVISION
Oregon Immunization Program
53-05A (04/2025)
↓ Oregon 53 05A PDF Form

Document Characteristics

Fact Name Details
Purpose The Oregon 53 05A form serves as a Certificate of Immunization Status, required for children attending school, preschool, or childcare.
Governing Law This form is governed by Oregon law, which mandates proof of immunization or a signed exemption before a child can attend educational facilities.
Information Collection Information collected on this form is shared with the Oregon Health Authority and local public health departments upon request.
Signature Requirement A parent, guardian, or eligible individual must sign the form to certify the accuracy of the immunization history.
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