Oregon PDF Docs

Oregon PDF Docs
Homepage ➼ Free Oregon 53 05A Form
Content Overview

The Oregon 53 05A form, formally known as the Certificate of Immunization Status, plays a crucial role in ensuring that children attending schools, preschools, child care facilities, or home daycares in Oregon are properly immunized against preventable diseases. This document not only serves as proof of immunization but also facilitates the collection of essential information on behalf of the Oregon Health Authority's Immunization Program. Parents or guardians must complete this form, providing details such as the child's full name, birthdate, and contact information, alongside a comprehensive list of vaccines received. The form requires the dates of each immunization to be recorded in the order they were administered, ensuring clarity and accuracy in tracking a child's vaccination history. Additionally, the Oregon 53 05A form accommodates exemptions, allowing parents to decline specific vaccines for medical or nonmedical reasons, provided that the appropriate documentation is submitted. By filling out this form, parents not only comply with state law but also contribute to the broader public health initiative aimed at preventing outbreaks of vaccine-preventable diseases.

Similar forms

  • CDC Vaccine Information Statement (VIS): This document provides information about vaccines, including benefits and risks, similar to the Oregon 53 05A form. It is often required to be given to parents before vaccination.
  • State Immunization Registry Form: Like the Oregon 53 05A form, this form collects a child's immunization history but is typically used for tracking purposes within state health departments.
  • School Immunization Record: Schools often require a similar record that details a child’s vaccination history, ensuring compliance with state laws regarding school attendance.
  • Health Care Provider Immunization Record: This document is filled out by a healthcare provider and serves as proof of vaccinations received, much like the Oregon 53 05A form.
  • Medical Exemption Form: This form is used when a child cannot receive vaccinations for medical reasons. It requires a physician's verification, paralleling the exemption options in the Oregon 53 05A form.
  • Non-disclosure Agreement: Similar to other important forms, the Non-disclosure Agreement protects sensitive information shared between parties. For more details on creating one, visit Forms Georgia.
  • Nonmedical Exemption Form: Similar to the Oregon 53 05A form, this document allows parents to exempt their child from vaccinations due to personal beliefs, requiring specific documentation.
  • Immunization History Report: This report provides a comprehensive history of a child's vaccinations, akin to the information requested on the Oregon 53 05A form.
  • Proof of Immunity Letter: This letter from a physician documents a child's immunity to certain diseases, similar to the immunity documentation section in the Oregon 53 05A form.
  • Child Health Record: This record includes various health information about a child, including immunization status, much like the Oregon 53 05A form.
  • Vaccine Educational Module Certificate: This certificate verifies that parents have completed educational training regarding vaccines, similar to the requirements outlined in the Oregon 53 05A form for nonmedical exemptions.

Preview - Oregon 53 05A Form

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)

(mm/dd/yy)

(mm/dd/yy)

(mm/dd/yy)

(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

Date

Update Signature

Date

Update Signature

Date

*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

Oregon Health Authority, Immunization Program

Child's Last Name

First

Middle Initial

Birthdate

Apellido

Primer Nombre

Segundo Nombre

Fecha de Nacimiento

�

Recommended Vaccines

Pneumococcal (PCV)

=

...�

(Only in children less than 5 years)

�

 

"CS

Meningococcal (MCV4, MPSV4)

 

�

Human Papilloma Virus (HPV)

"CS

e

(9 years or older)

=

�

 

e

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

•Physician's signature and date

Dose 1

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

 

Date

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

Date

Update Signature

Update Signature

Update Signature

Date

Date

Date

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.

Key takeaways

  • Complete Information: Provide full details for your child, including their last name, first name, middle initial, birthdate, mailing address, and the names and contact information of parents or guardians. This ensures that the school or childcare facility can reach you if there are any questions regarding your child's immunization history.
  • Document Immunizations: List each vaccine your child has received in the order they were administered. Make sure to fill in the dates for each dose accurately, as this information is essential for compliance with Oregon law.
  • Required vs. Recommended Vaccines: The form distinguishes between required vaccines and those that are recommended. While required vaccines must be documented, recommended vaccines are also important for your child’s health and should be included if received.
  • Signatures Matter: The form requires a signature from a parent, guardian, or eligible individual to verify that the information is accurate. If you add new information, remember to sign again to confirm the updates.
  • Exemption Options: If you choose to exempt your child from certain vaccinations, you must indicate this on the form. Oregon allows both medical and nonmedical exemptions, each requiring specific documentation to support your request.
  • Double-Check Both Sides: The Oregon 53 05A form has important information on both sides. Ensure that you complete and review both sides before submission to avoid any delays or issues with your child’s enrollment in school or childcare.

Find Other Templates

Oregon Small Claims Court Forms - The form serves as a necessary notice that initiates the legal process for small claims.

In order to facilitate a seamless vehicle transaction in California, it is important for both buyers and sellers to familiarize themselves with the California Vehicle Purchase Agreement form, which can be obtained from legalpdf.org. This legally binding document not only specifies the terms of the sale but also serves as a record of essential details, including the sale price and any warranties provided. Properly completing this form can help avoid ambiguities and ensure that both parties are protected throughout the transaction.

Oregon Income Tax Form - The form outlines the specific legal contexts in which it can be applied, such as marriage or registered domestic partnerships.

File Details

Fact Name Details
Form Purpose The Oregon 53 05A form serves to document a child's immunization status for school or childcare attendance.
Governing Law Oregon law mandates proof of immunization or a signed exemption prior to a child's attendance at school or childcare facilities.
Required Information Parents must provide the child's full name, birthdate, mailing address, and parents’ or guardians’ names and phone numbers.
Immunization Records Vaccination dates must be listed in the order received, including required and recommended vaccines.
Exemption Types Oregon allows for both medical and nonmedical exemptions from vaccinations.
Signature Requirement A parent, guardian, or eligible individual must sign the form to verify the accuracy of the immunization record.
Submission Guidelines For medical exemptions, a physician's letter detailing the child's medical condition must be submitted along with the form.

Documents used along the form

The Oregon 53 05A form, known as the Certificate of Immunization Status, is essential for documenting a child's immunization history before attending school or childcare. Alongside this form, several other documents may be required to ensure compliance with state immunization laws. Below is a list of related forms and documents that are commonly used in conjunction with the Oregon 53 05A form.

  • Medical Exemption Letter: This letter, signed by a licensed physician, outlines the child's medical condition that contraindicates vaccination. It must include the child's name, birth date, and a list of vaccines that are not recommended due to the medical condition.
  • Proof of Immunity Documentation: A letter from a physician is required to confirm a child's immunity to certain diseases. This letter should include the child's name, birth date, and a diagnosis or lab report that supports the claim of immunity.
  • Nonmedical Exemption Certificate: For parents opting out of vaccinations for personal beliefs, this document must be signed by a healthcare practitioner. It verifies that the parent has been informed about the benefits and risks of immunization.
  • Educational Module Completion Certificate: Parents may complete a state-approved educational module regarding vaccinations. A certificate of completion must be submitted if they choose a nonmedical exemption.
  • School Admission Form: Many schools require an additional form for enrollment that includes the child's personal information and immunization status. This form is often separate from the Oregon 53 05A but is necessary for admission.
  • Health History Form: Some schools and childcare facilities ask for a comprehensive health history form. This document provides details about the child's overall health, including any allergies or chronic conditions.
  • Small Estate Affidavit: To facilitate the transfer of assets without probate, parents may find the necessary small estate affidavit resources essential for managing estate distribution efficiently.
  • Emergency Contact Form: This form is essential for schools and childcare facilities to have on file. It includes emergency contacts for the child, ensuring that caregivers can reach someone in case of an emergency.

Understanding these documents and their purposes can help parents navigate the immunization requirements in Oregon effectively. Having the necessary paperwork ready will facilitate a smoother enrollment process for children entering school or childcare settings.