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
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 Inuenzae Type B
Tipo B (Hib)
Oregon Certicate of Immunization Status
Certicado 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.
Certico 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 benets 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 benecios 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 losócas
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
Certicate 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 certicate signed by a health care practitioner verifying discussion of the benets and risks of
immunization, or
2. A certicate of completion of the vaccine educational module about the benets 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
Certicado 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 certicado rmado por un proveedor de atención de salud vericando la discusión de los benecios
y riesgos de la vacunación, o
2. Un certicado de terminación del módulo educativo de la vacuna sobre los benecios 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)
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.
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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.