Immunization Forms

Student Immunization Forms

Universal Health Certificate (UHC)

• Used to report a child’s physical health to their school and/or childcare facility.

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Immunization Religious Exemption Certificate  

• The Immunization Religious Exemption Certificate documents an exemption from required immunizations based on sincerely held religious beliefs.
• It must be completed annually by the parent or guardian of the student or child, or by the student if they are over age 18.
• It is valid for one school year (July 1 through June 30).
• A separate exemption certificate is required for each student or child.

Instructions for completing this certificate:

• Section 1: Enter information of child or student and requestor.
• Section 2: Check, Initial, and date vaccines for exemption.
• Section 3: Print name, sign, and date.
• Submission: This certificate or another writing should be submitted to the public health authorities (DC Health) by way of the student's school or licensed child care facility.
  • Schools and licensed child care facilities are responsible for submitting the completed document to DC Health through the Self-Service Portal (SSP).

 

HPV Vaccination Opt-Out Certificate

• The human papillomavirus (HPV) vaccine is a routine immunization recommended for children ages 11-12, and can be initiated as early as age 9, offering protection against certain cancers later in life.
• The Annual Human Papillomavirus (HPV) Vaccination Opt-Out Certificate documents the parent/guardian decision to opt-out of the HPV vaccine school requirement.
• It must be completed annually by the parent or guardian of the student or child, or by the student if they are over age 18.
• It is valid for one school year (July 1 through June 30).

Instructions for completing this certificate:

• Section 1: Read the information sheet on HPV and the HPV Vaccine.
• Section 2: Enter information of child or student. Sign and date.
• Submission: This certificate or another writing should be submitted to the public health authorities (DC Health) by way of the student's school.
  • Schools are responsible for submitting the completed document to DC Health through the Self-Service Portal (SSP).

 

Translated Documents - Immunization Forms