Form 121 Certificate of Immuniz - CRASH Course

1 compliance form Instruction 2009 form No. 121 Certificate of immunization ComplianceName of Child/Student/Employee _____ Birthdate _____Name of Parent _____Address _____Street City State ZipDate Each Dose Was GivenVaccine1st2nd3rd4th5thPneumococcalV aricellaDTaP/DT/TdHibPolioMMRHep BTdapOther Check here if prior history of chicken pox Medical Exemption form 122 attachedThe individual named above has met the immunization requirements for attendance or employment in a Mississippi child carefacility or entry into a Mississippi public or private school, college, or check ( ) one box onlyDate of serological confirmation of immunity*Varicella _____ / _____ / _____ Complete Until School Entry Month DayYear*Measles _____ / _____ / _____ Complete for school entry (K4-6th grade)Month DayYear Complete for middle school, high school, university/college, *Rubella _____ / _____ / _____work requirements (7th grade and above)

2 Month Day Year Temporarily compliant-next immunization is due _____/_____/_____*Mumps _____ / _____ / _____Month Day YearMonth Day Year Record in transit, valid until _____/_____/_____Month Day Year*Serological testing for the above are the only acceptable titers that will be allowed for child care and school entryfor those who are not fully _____ _____/_____/_____Print or Stamp Name of FacilitySignature and Title of Issuing IndividualMonth Day YearHib and Pneumococcal vaccines are only required for child 5/17/12 form No. 121 ESPECIAL INSTRUCTIONSC hild Care Facilities:As a part of the child care regulations, every facility must have a Certificate ofImmunization compliance form ( form 121) or the white computer generated version of the form on file for each child enrolled.

3 Each child must be up-to-dateon all required Care Operators:A copy of the 121 compliance Forms and roster of all children enrolled must be retained by the child care facility in a central location for appropriate review. Incomplete forms should be retained in a separate file for appropriate review and 12th Grade:All kindergarten, first grade entrants who did not attend kindergarten, first timestudents, and students transferring to a Mississippi school from an out-of-stateschool must be vaccinated on all requiredschool vaccines. Hib and Pneumococalvaccines are only required for child Officials:This form or a copy must be filed permanently in the student s cumulative a student transfer, the Certificate of compliance form is to be sent withthe cumulative folder. compliance forms and an enrollment roster should beretained in a separate file for appropriate review.

4 Incomplete forms should beretained in a separate file for appropriate review and follow-up. College Students:Two doses of the MMR vaccine are recommendedfor all first-time enterers to member institutions of the Mississippi university systems. Other colleges andjunior colleges in the state have chosen to implement a measles-rubella immunitystandard for college admission. Students should check with their college for required Officials:This form should be kept in a permanent file and accessible to representatives of theMississippi State Department of Health upon request. Officials should check with theircollege for required immunizations. The original or a copy of this form should betransferred with the student, should a change in educational institution :Employees must provide proof of immunity to measles and rubella. A completedand signed form should be submitted to your employer as proof of compliancewith immunity requirements for :This form should be kept in a permanent file accessible to representatives of the Mississippi State Department of Health upon :The Varicella vaccine is a required vaccine for child care and school reliable history of chicken pox is students enrolling and/or transferring into 7th grade are required to havethe Care Providers:Re- immunization is necessary when:1.

5 Measles vaccine was administered before 12 months of age and/or beforeJanuary 1, Rubella vaccine was administered before 12 months of age and/or before Varicella vaccine was administered before 12 months of not required and when:Measles or Rubella vaccines are not required for females who are pregnant. If pregnancy is suspected, a valid Certificate of Medical Exemption fromImmunization Requirements for Adults ( form Number 122)is required until pregnancy is resolved. Measles or Mumps vaccines are not required for persons born before January 1, 1957.