KS Certificate of Immunization (KCI) - Form B 2015 free printable template
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Kansas Immunization Program 1000 SW Jackson Suite 210 Topeka, KS 666121274 Phone: 8558967337 Fax: 7852966510 program the.ks.gov www.kdheks.gov/immunize KANSAS CERTIFICATE OF IMMUNIZATIONS FORM B MEDICAL
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How to fill out KS Certificate of Immunization (KCI) - Form B
01
Obtain the KS Certificate of Immunization (KCI) - Form B from the appropriate health department or school office.
02
Fill in the child's full name and date of birth at the top of the form.
03
List all required immunizations received by the child, including dates of administration for each vaccine.
04
Provide the name and address of the healthcare provider or clinic administering the vaccines.
05
Ensure that the form is signed and dated by a healthcare provider, confirming the accuracy of the information.
06
Submit the completed form to the school or institution requiring the KCI.
Who needs KS Certificate of Immunization (KCI) - Form B?
01
Children enrolling in school or daycare settings in Kansas.
02
Students transferring from another state or educational institution.
03
Individuals who need to meet state immunization requirements for specific activities or programs.
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What is KS Certificate of Immunization (KCI) - Form B?
The KS Certificate of Immunization (KCI) - Form B is a document used in Kansas to record immunization history for children attending school or childcare facilities.
Who is required to file KS Certificate of Immunization (KCI) - Form B?
Parents or guardians of children enrolling in child care facilities or schools in Kansas are required to file the KS Certificate of Immunization (KCI) - Form B.
How to fill out KS Certificate of Immunization (KCI) - Form B?
To fill out the KS Certificate of Immunization (KCI) - Form B, provide the child's personal details, enter the dates of their immunizations, and include the signature of a healthcare provider to verify the information.
What is the purpose of KS Certificate of Immunization (KCI) - Form B?
The purpose of the KS Certificate of Immunization (KCI) - Form B is to ensure that children are up-to-date on their vaccinations to protect them and the community from vaccine-preventable diseases.
What information must be reported on KS Certificate of Immunization (KCI) - Form B?
The information that must be reported on KS Certificate of Immunization (KCI) - Form B includes the child's name, date of birth, the type of immunizations received, the dates of the immunizations, and the healthcare provider's signature.
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