DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-04020L (05/2024)
STATE OF WISCONSIN
Wis. Stat. §§ 252.04 and 120.12 (16)
STUDENT IMMUNIZATION RECORD
Instructions to Parent: Complete and return to school within 30 days after admission. State law requires all public and private school students to present
written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific requirements are available
from schools and local health departments. These requirements can only be waived if a properly signed health, religious or personal conviction waiver is filed
with the school. The purpose of this form is to measure compliance with the law and will be used for that purpose only. If you have questions regarding
immunizations, or how to complete this form, contact your child’s school or local health department.
Step 1
Personal Data
Please Print
Student’s Name
Birthdate (MM/DD/YYYY)
School
Grade
School Year
Name of Parent/Guardian/Legal Custodian
Address (Street, City, State, ZIP Code)
Phone Number
Step 2
Immunization History
List the month, day, and year your child received each of the following immunizations. If you do not have an immunization record for this student,
contact your doctor or public health department to obtain it. You may also use the Wisconsin Immunization Registry:
https://www.dhfswir.org/PR/clientSearch.do?language=en
Type of Vaccine*
First Dose
MM/DD/YYYY
Second Dose
MM/DD/YYYY
Third Dose
MM/DD/YYYY
Fourth Dose
MM/DD/YYYY
Fifth Dose
MM/DD/YYYY
DTaP/DTP/DT/Td (Diphtheria, Tetanus, Pertussis)
Adolescent booster (Check appropriate box)
Tdap Td
Polio
Hepatitis B
MMR
(Measles, Mumps, Rubella)
Varicella (Chickenpox) Vaccine
Meningococcal (serogroup ACWY)
Students with a reliable history of varicella disease are not required to
receive the varicella vaccine. Signature from physician, physician
assistant, or advanced nurse prescriber required.
I attest that this student has a reliable history of varicella disease,
_______________________________________________________
SIGNATURE – Health Care Provider
Date Signed
Has your child had a blood test (titer) that shows immunity (had disease
or previous vaccination) to any of the following? Check all that apply.
Varicella Measles Mumps Rubella Hepatitis B
If yes, provide laboratory report(s)
Step 3
Requirements
Refer to the age/grade level requirements for the current school year to determine if this student meets the requirements.
Step 4
Compliance Data
Student Meets All Requirements
Sign at Step 5 and return this form to school.
Or
Student Does Not Meet All Requirements
Check the appropriate box below, sign at Step 5, and return this form to school. Please note that incompletely immunized students may be
excluded from school if an outbreak of one of these diseases occurs.
Although my child has not received all the required doses of vaccine, the first dose(s) has/have been received. I understand that the second
dose(s) must be received by the 90th school day after admission to school this year, and that the third dose(s) and fourth dose(s) if
required must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in writing each
time my child receives a dose of required vaccine.
Note: Failure to stay on schedule may result in exclusion from school, court action and/or forfeiture penalty.
Waivers (List in Step 2 above, the date(s) of any immunizations your child has already received)
For health reasons this student should not receive the following immunizations _________________________________________
_________________________________________________________________________ ______________________________________
SIGNATURE – Physician Date Signed
For religious reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)
DTaP/DTP/DT/Td Tdap, Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella MenACWY
For personal conviction reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)
DTaP/DTP/DT/Td Tdap Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella MenACWY
Step 5
Signature
This form is complete and accurate to the best of my knowledge. Check one: (I do I do not ) give permission to share my child’s current
immunization records and as they are updated in the future with the Wisconsin Immunization Registry (WIR). I understand that I may revoke this
consent at any time by sending written notification to the school district. Following the date of revocation, the school district will provide no new
records or updates to the WIR.
________________________________________________________________________ ________________________________________
SIGNATURE - Parent/Guardian/Legal Custodian or Adult Student Date Signed