MDH_896_form

MARYLAND DEPARTMENT OF HEALTH IMMUNIZATION CERTIFICATE
STUDENT/SELF NAME: ___________________________________________________________________________________________

LAST FIRST MI
STUDENT/SELF ADDRESS: ____________________________________________ CITY: _____________________ ZIP: _________
SEX: MALE □ FEMALE □ OTHER □ BIRTH DATE: __________/_________/__________
COUNTY: _________________________________ SCHOOL: _____________________________________________ GRADE: _______
FOR MINORS UNDER 18:

PARENT/GUARDIAN NAME: ___________________________________________ PHONE #: ____________________________
DTP-DTaP-DT Polio Hib Hep B PCV Rotavirus MCV HPV Hep A MMR Varicella Varicella COVID-19
# Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Disease Mo/Day/Yr
Mo / Yr
1 DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE
#1 #1 #1 #1 #1 #1 #1 #1 #1 #1 #1 #1 #6
__________
2 DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE
#2 #2 #2 #2 #2 #2 #2 #2 #2 #2 #2 #2 #7
3 DOSE DOSE DOSE DOSE DOSE DOSE DOSE DOSE Td Tdap MenB Other DOSE DOSE
#3 #3 #3 #3 #3 #3 #3 #3 Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr #3 #8
4 DOSE DOSE DOSE DOSE DOSE ____ ____ ____ _____ DOSE DOSE
#4 #4 #4 #4 #4 #4 #9
____ ____ ____ _____
5 DOSE DOSE DOSE DOSE
#5 #5
____ ____ _____ #5 #10
To the best of my knowledge, the vaccines listed above were administered as indicated. Clinic / Office Name
Office Address/ Phone Number
1. _____________________________________________________________________________
Signature Title Date
(Medical provider, local health department official, school official, or child care provider only)
2. _____________________________________________________________________________
3. _____________________________________________________________________________
Lines 2 and 3 are for certification of vaccines given after the initial signature.
COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL
OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE.
MEDICAL CONTRAINDICATION:
Please check the appropriate box to describe the medical contraindication.

This is a: □ Permanent condition OR □ Temporary condition until _______/________/________
Date
The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the
contraindication,
Signed: _____________________________________________________________________ Date _______________________

Medical Provider / LHD Official
RELIGIOUS OBJECTION:
I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any vaccine(s)
being given to my child. This exemption does not apply during an emergency or epidemic of disease.
Signed: _____________________________________________________________________ Date: _______________________
MDH Form 896 (Formally DHMH 896) Center for Immunization

Rev. 10/22 www.health.maryland.gov/Imm
How To Use This Form
The medical provider that gave the vaccinations may record the dates (using month/day/year) directly on this form
(check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be
listed individually, by each component of the vaccine. A different medical provider, local health department official,
school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record
which has the authentication of a medical provider, health department, school, or child care service.
Only a medical provider, local health department official, school official, or child care provider may sign
‘Record of Immunization’ section of this form. This form may not be altered, changed, or modified in any way.
Notes:
1. When immunization records have been lost or destroyed, vaccination dates may be reconstructed for all vaccines
except varicella, measles, mumps, or rubella.
2. Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local health
department no later than 20 calendar days following the date the student was temporarily admitted or retained.
3. Blood test results are NOT acceptable evidence of immunity against diphtheria, tetanus, or pertussis
(DTP/DTaP/Tdap/DT/Td).
4. Blood test verification of immunity is acceptable in lieu of polio, measles, mumps, rubella, hepatitis B, or
varicella vaccination dates, but revaccination may be more expedient.
5. History of disease is NOT acceptable in lieu of any of the required immunizations, except varicella.
Immunization Requirements
The following excerpt from the MDH Code of Maryland Regulations (COMAR) 10.06.04.03 applies to schools:
“A preschool or school principal or other person in charge of a preschool or school, public or private, may not
knowingly admit a student to or retain a student in a:
(1) Preschool program unless the student's parent or guardian has furnished evidence of age-appropriate immunity
against Haemophilus influenzae, type b, and pneumococcal disease;
(2) Preschool program or kindergarten through the second grade of school unless the student's parent or guardian has
furnished evidence of age-appropriate immunity against pertussis; and
(3) Preschool program or kindergarten through the 12th grade unless the student's parent or guardian has furnished
evidence of age-appropriate immunity against: (a) Tetanus; (b) Diphtheria; (c) Poliomyelitis; (d) Measles
(rubeola); (e) Mumps; (f) Rubella; (g) Hepatitis B; (h) Varicella; (i) Meningitis; and (j) Tetanus-diphtheria-
acellular pertussis acquired through a Tetanus-diphtheria-acellular pertussis (Tdap) vaccine.”
Please refer to the “Minimum Vaccine Requirements for Children Enrolled in Pre-school Programs and in
Schools” to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccine
requirements and MDH COMAR 10.06.04.03 are available at www.health.maryland.gov. (Choose Immunization in the
A-Z Index)
Age-appropriate immunization requirements for licensed childcare centers and family day care homes are based on the
Department of Human Resources COMAR 13A.15.03.02 and COMAR 13A.16.03.04 G & H and the “Age-
Appropriate Immunizations Requirements for Children Enrolled in Child Care Programs” guideline chart are
available at www.health.maryland.gov. (Choose Immunization in the A-Z Index)
MDH Form 896 (Formally DHMH 896) Center for Immunization
Rev. 10/22 www.health.maryland.gov/Imm

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MARYLAND DEPARTMENT OF HEALTH IMMUNIZATION CERTIFICATE

STUDENT/SELF NAME: ___________________________________________________________________________________________

STUDENT/SELF ADDRESS: ________________________________ CITY: _ ZIP: _

SEX: MALE □ FEMALE □ OTHER □ BIRTH DATE: ______/_/______

COUNTY: _ SCHOOL: _______ GRADE: _

FOR MINORS UNDER 18:

Please check the appropriate box to describe the medical contraindication.

Signed: _______________________________________________ Date _

Signed: _______________________________________________ Date: _

MDH Form 896 (Formally DHMH 896) Center for Immunization

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