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DEPARTMENT OF HEALTH SERVICES Division of Public Health F04020L (Rev. 05/11)STATE OF WISCONSIN 252.04 and 120.12 (16) Wis. Stats.STUDENT IMMUNIZATION RECORD INSTRUCTIONS TO PARENT: COMPLETE AND RETURN

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How to fill out student immunization record

01

Step 1: Obtain a copy of the student immunization record form from the school or healthcare provider.

02

Step 2: Gather the necessary information, including the student's full name, date of birth, and contact information.

03

Step 3: Provide details about the immunizations received by the student, such as the name of the vaccine, date administered, and the administering healthcare provider.

04

Step 4: Make sure to include any exemptions or medical waivers if applicable.

05

Step 5: Review the completed form for accuracy and completeness.

06

Step 6: Submit the filled-out student immunization record to the appropriate organization, such as the school or healthcare provider, as required.

Who needs student immunization record?

01

Any student enrolled in an educational institution that requires proof of immunization would need a student immunization record.

02

This includes students entering kindergarten, primary or secondary school, college, or university.

03

Additionally, students involved in certain extracurricular activities or specific healthcare programs may also be required to provide a student immunization record.

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What is student immunization record?

Student immunization record is a document that shows the vaccines a student has received.

Who is required to file student immunization record?

Parents or guardians are required to file student immunization records for their children.

How to fill out student immunization record?

Student immunization records can be filled out by providing information on the vaccines received by the student, including the date and type of each vaccine.

What is the purpose of student immunization record?

The purpose of student immunization record is to ensure that students are vaccinated against preventable diseases and to track their immunization history.

What information must be reported on student immunization record?

Student immunization records must include the name of the student, date of birth, vaccines received, dates of vaccination, and healthcare provider information.

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