Transcription of CERTIFICATE OF IMMUNIZATION - Grits
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CERTIFICATE OF IMMUNIZATION - Grits
Form 3231 Georgia Department of Public HealthCERTIFICATE OF IMMUNIZATIONRev. 07/2020 BirthdateDate of Expiration(Next required immunizationor review of medicalexemption due.)(Fill in X)Complete For K through 6th GradeChild must be >= 4 years and have met all requirements for school attendance.(Fill in X)Complete For 7th through 10th GradeFulfills requirements K through 6th gradeAND must have Tdap and MCV4 administered.(Fill in X)Complete For 11th Grade and higherFulfills requirements K through 10th gradeAND must have MCV4 booster dose administered on or after 16th birthday.(Optional) Parent/Guardian Name (Last name, First name)Unless specifically exempted by law, Georgia law ( 20-2-771) requires acertificate on file for each child in attendance in any school or child care facility inGeorgia with penalties for failure to comply.
Rev. 07/2014 Georgia Department of Public Health CERTIFICATE OF IMMUNIZATION Form 3231 (Fill in X) Child's Name (Last name first) Birthdate Date of Expiration (Fill …
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