Free Oregon 53 05A PDF Form

The Oregon 53 05A form, officially known as the Oregon Certificate of Immunization Status, is a critical document for parents and guardians in Oregon. It is a requirement by Oregon law to provide proof of immunization or sign an exemption before a child can attend school, preschool, child care, or home day care. The form collects vaccination records on behalf of the Oregon Health Authority, Immunization Program, and may be shared with the Authority or local public health departments upon request.

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In Oregon, ensuring the health and safety of children in educational and childcare settings is a priority, which is reflected in the requirements surrounding the Oregon 53 05A form, also known as the Oregon Certificate of Immunization Status. This crucial document serves as proof of a child's immunizations, aligning with state laws that mandate up-to-date vaccinations or a signed exemption before a child can attend school, preschool, child care, or home daycare. The form, collected on behalf of the Oregon Health Authority, Immunization Program, plays a key role in public health efforts to prevent and control vaccine-preventable diseases within the community. It meticulously records a child’s vaccination history, detailing the types of vaccines administered and the dates they were received. Additionally, the form accommodates medical and nonmedical exemptions, providing space for parents and guardians to indicate their reasons for opting out of certain vaccinations, subject to the provision of supporting documentation. By streamlining the process of recording and verifying vaccination records, the form assists schools and childcare facilities in compliance with health regulations, ultimately contributing to the broader goal of safeguarding public health.

Document Example

Oregon Certi! cate of Immunization Status

Oregon Health Authority, Immunization Program

Oregon law requires proof of immunization be provided or an exemption be signed prior to a child’s attendance at school, preschool, child care or home day care. This information is being collected on behalf of the Oregon Health Authority, Immunization Program and may be released to the Authority or the local public health department by the school or children’s facility upon request of the Authority. Please list immunizations in the order they were received.

Child’s Last Name			First		Middle Initial	Birthdate
Apellido			Primer Nombre		Segundo Nombre	Fecha de Nacimiento

Mailing Address			City		State	Zip Code
Dirección			Ciudad		Estado	Codigo Postal

Parents’ or Guardians’ Names					Home Telephone Number
Nombre de los padres o guardian					Número de Teléfono

Vaccines			Dose 1	Dose 2	Dose 3	Dose 4	Dose 5
Diphtheria/Tetanus/Pertussis			(mm/dd/yy)	(mm/dd/yy)	(mm/dd/yy)	(mm/dd/yy)	(mm/dd/yy)
	(DTaP, Tdap, Td)

	Booster Dose Tdap

Polio (IPV or OPV)

Varicella (Chickenpox) [VZV or VAR]
	o	Check here if child has had chickenpox
		disease ____________ (mm/dd/yy)

Measles/Mumps/Rubella (MMR)

Measles vaccine only

Mumps vaccine only

Rubella vaccine only

Hepatitis B (Hep B)

Hepatitis A (Hep A)

Haemophilus In! uenzae Type B (Hib) (Only children less than 5 years)

I certify that the above information is an accurate record of this child’s immunization history.

for all	Complete
Up-to- date
	Medical
medical	Non

Signature*

Date

Update Signature

Date

Update Signature

Date

Update Signature

Date

*Parent, guardian, student at least 15 years of age, medical provider or county health department staff person may sign to verify vaccinations received.

For school/facility use only

School/facility Name

Student ID Number

Grade

Continued On Reverse Side

Oregon Certificate of Immunization Status, Page 2

Oregon Health Authority, Immunization Program

Child's Last Name	First	Middle Initial	Birthdate
Apellido	Primer Nombre	Segundo Nombre	Fecha de Nacimiento

	�	Recommended Vaccines
	�	Pneumococcal (PCV)
	=	Pneumococcal (PCV)
	...�	(Only in children less than 5 years)
	�
	"CS	Meningococcal (MCV4, MPSV4)
	"CS
	�	Human Papilloma Virus (HPV)
	"CS	Human Papilloma Virus (HPV)
	e	(9 years or older)
	=	(9 years or older)
	�
	e	Influenza (Flu)

�

�Other Vaccine

�Please specify:

Other Vaccine Please specify:

For medical exemptions:

Please submit a letter signed by a licensed physician stating:

•Child's name

•Birth date

•Medical condition that contraindicates vaccine

•List of vaccines contraindicated

•Approximate time until condition resolves, if applicable

•Physician's signature and date

•Physician's contact information, including

phone number

For Immunity Documentation (history ofdisease or positive titer): Please submit a letter signed by a licensed physician stating:

•Child's name and birth date

•Diagnosis or lab report

•Physician's signature and date

Dose 1

Dose2

Dose3

Dose4

Doses

Nonmedical Exemption:

I have received information regarding the benefits and risks of immunizations. I understand that my child may be excluded from school or child care attendance ifthere is a case ofdisease that could be prevented by vaccine. I have attached the required document from (check one):

A health care practitioner

The vaccine educational module approved by the Oregon Health Authority

I understand that I may decline one or more vaccinations for my child and request that my
child be exempted from the following required immunizations (check all that apply):
	Diphtheria/ Tetanus/Pertussis	Hepatitis B
	Diphtheria/ Tetanus/Pertussis	Hepatitis B
	Polio	Hepatitis A
	Polio	Hepatitis A
	Varicella	Hib
	Measles/Mumps/Rubella	Date
Signature of Parent or Guardian		Date

Optional:

ORS 433.267 states that this document may include the reason for declining the immunization. Immunization is being declined because of:

Religious belief

Philosophical belief

Other

I certify that the above information is an accurate record of this child's immunization history and exemption status.

Signature

Date

Update Signature

Date

Date	53-05A (01/2019)

Instructions for completing the

Certificate of Immunization Status

Contact information:

Complete information for your child including full name, birthdate, current mailing address, parentsÕ or guardiansÕ names and home telephone number. This information will be used to contact you if there are questions about your childÕs immunization history.

Required vaccines (Front):

Fill in the month/day/year that your child received each dose of vaccine. Doses must be listed in the order received. The shaded boxes on the form indicate doses that are not routinely given, however if your child received them, please write the date in the shaded box. Check with your childÕs school or daycare to find out which vaccines are required for your childÕs age or grade.

Recommended vaccines (Back):

These doses are not required by law, however these vaccines are recommended and most children receive them. Fill in the month/day/year that your child received each dose of vaccine. Doses should be listed in the order received. The shaded boxes on the form indicate doses that are not routinely given, however if your child received them, please write the date in the shaded box.

Signature:

The parent or guardian signature is a sworn statement that the childÕs record is accurate. The signature of a physician or local health department is not required but it is acceptable. Every time

you add on to your child’s information you need to resign the form.

REMEMBER TO COMPLETE BOTH SIDES OF FORM

Exemptions:

Oregon allows medical and nonmedical exemptions.

For a nonmedical exemption, check the appropriate box and submit one of the following required documents:

1.A certificate signed by a health care practitioner verifying discussion of the benefits and risks of immunization, or

2.A certificate of completion of the vaccine educational module about the benefits and risks of

immunization.

Indicate which vaccines you are exempting your child from by checking the boxes. Sign and date on the indicated line.

For a medical exemption or proof of immunity, submit a letter from your childÕs physician to the school or child care.

Instrucciones para llenar el

Certificado de Estado de Vacunación

Informaci—n de contacto:

DŽ la siguiente informaci—n sobre su hijo: nombre completo, fecha de nacimiento, direcci—n postal actual, nombres y nœmeros de telŽfono de los padres o tutores. Usaremos esta informaci—n para comunicarnos con usted si hay preguntas sobre los datos de vacunaci—n de su hijo.

Vacunas requeridas (adelante):

Escriba el mes/d’a/a–o en que su hijo recibi— cada dosis de vacuna. Las dosis se deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario indican las dosis que no se dan rutinariamente. Sin embargo, si su hijo las recibi—, escriba la fecha en el casillero sombreado. Averiguar con la escuela o guarder’a cuales son las vacunas requeridas para la edad y grado escolar de su ni–o.

Vacunas recomendadas (atr‡s):

Estas dosis no son obligatorias por ley, pero son recomendadas y la mayor’a de los ni–os las reciben. Escriba el mes/d’a/a–o en que su hijo recibi— cada dosis de vacuna. Las dosis se deben enumerar en el orden en que fueron recibidas. Los casilleros sombreados del formulario indican las dosis que no se dan rutinariamente. Sin embaro, si su hijo las recibi—, escriba la fecha en el casillero sombreado.

Firma:

La firma del padre, madre o tutor es una declaraci—n jurada de que la historia de vacunas del ni–o esta correcta. La firma del mŽdico o del departamento de salud local no son requieridas, pero son aceptable. Cada vez que agregue datos a la información sobre su hijo debe

volver a firmar el formulario.

RECUERDE LLENAR AMBOS LADOS DEL FORMULARIO

Excepciones:

Oregon permite excepciones mŽdicas y no mŽdicas.

Para una excepci—n no mŽdica, marque la casilla adecuada y presente uno de los siguientes documentos requeridos:

1.Un certificado firmado por un proveedor de atenci—n de salud verificando la discusi—n de los beneficios y riesgos de la vacunaci—n, o

2.Un certificado de terminaci—n del m—dulo educativo de la vacuna sobre los beneficios y

riesgos de la vacunaci—n.

Indique para cu‡les vacunas quiere que su hijo(a) sea exento(a) al marcar las casillas. Firme y feche la l’nea indicada.

Para una excepci—n mŽdica o un comprobante de inmunidad, presente una carta del doctor de su hijo(a) a la escuela o cuidado infantil.

Download PDF File

File Features

Fact Name	Description
Form Purpose	The Oregon 53 05A form serves as a Certificate of Immunization Status, required by Oregon law for children attending school, preschool, child care, or home day care.
Governing Law	Oregon law mandates the provision of proof of immunization or a signed exemption prior to attendance at any educational or child care facility.
Collected Information	This form collects detailed information about a child's immunization history, including types of vaccines received and the dates of administration.
Required Vaccines	Vaccines listed may include Diphtheria/Tetanus/Pertussis, Polio, Varicella, Measles/Mumps/Rubella, Hepatitis B, Hepatitis A, and Haemophilus Influenzae Type B, among others.
Exemption Options	Parents or guardians may request exemptions for medical or personal reasons, subject to submitting required documentation.
Signature Requirement	The form must be signed by a parent, guardian, student (if at least 15 years old), medical provider, or county health department staff to verify the vaccination information provided.
Additional Recommendations	While certain vaccines are required, the form also lists recommended vaccines not mandated by law, to encourage broader protection against diseases.

Oregon 53 05A: Usage Guide

After gathering all necessary immunization records and reviewing the specific requirements for school attendance in Oregon, it's time to accurately complete the Oregon 53 05A Certificate of Immunization Status form. This step ensures your child meets Oregon's immunization laws for school, preschool, child care, or home day care attendance. Below are detailed instructions to assist you in filling out the form correctly.

Begin by entering the child's Last Name, First Name, Middle Initial, and Birthdate (mm/dd/yy) in the designated spaces.
Input the child's Mailing Address, including the City, State, and Zip Code.
Provide the Names of Parents or Guardians and a reliable Home Telephone Number for contact.
In the section labeled "Vaccines," record the dates (mm/dd/yy) for each dose received. Make sure to list these in the chronological order they were administered. If your child has had chickenpox disease, check the appropriate box to indicate this.
If the child has received any recommended vaccines (listed on the reverse side of the form), document the dates for each dose in the respective areas. Again, these should be in the order they were given. For vaccines not routinely administered (indicated by shaded boxes), only fill these out if applicable.
Under the sections marked Medical Update and Nonmedical Update, sign and date to verify the accuracy of the recorded immunization history. If changes or updates are made to the form at any time, these sections must be resigned and dated.
For exemptions, clearly indicate whether you are submitting a Medical or Nonmedical Exemption. For nonmedical exemptions, attach the necessary documentation as outlined: either a certificate from a health care provider or a completion certificate from the vaccine educational module. Check the specific vaccines from which the child is exempted. Sign and date on the provided lines.
For medical exemptions or immunity documentation, include a letter from a licensed physician detailing the child's name, birth date, specific medical condition contraindicating vaccines (if applicable), the list of vaccines contraindicated, and the expected resolution time of the condition. Ensure the physician's signature and date are included alongside their contact information.
Before submission, double-check all entries for accuracy and completeness. Remember, this form must be filled out on both sides.

Upon completion of the Oregon 53 05A form, it becomes a crucial record of your child's immunization status and exemption requests. It must be submitted to the school or children's facility your child will be attending. This document ensures your child's compliance with Oregon's immunization laws and assists in safeguarding the health of all children in educational and care settings.

Crucial Points on Oregon 53 05A

What is the Oregon 53 05A form?

The Oregon 53 05A form, also known as the Oregon Certificate of Immunization Status, is a document required by the Oregon Health Authority, Immunization Program. It's used to prove a child's immunization history or to provide a record of an exemption signed before the child attends school, preschool, child care, or home day care. This form helps ensure compliance with Oregon's laws regarding vaccination requirements for children in these settings.

Who needs to complete the Oregon 53 05A form?

This form must be completed by parents or guardians of children who are enrolling in school, preschool, child care, or home day care facilities in Oregon. Additionally, students aged 15 years or older can sign the form themselves to verify vaccinations received. Medical providers or county health department staff may also sign the form when verifying vaccinations.

What information is required on the Oregon 53 05A form?

To fill out the form accurately, you will need:

The child’s full name, birthdate, and mailing address along with the city, state, and zip code.
The names of the child’s parents or guardians and a home telephone number.
Details of the vaccines received by the child, including the type of vaccine and the dates of doses administered.
A signature from a parent, guardian, the student (if at least 15 years old), a medical provider, or a county health department staff person to verify the vaccinations.

How do you obtain exemptions through this form?

Oregon law allows for both medical and nonmedical exemptions for vaccines. To claim an exemption:

For a nonmedical exemption, you must either submit a certificate signed by a healthcare practitioner verifying that you have been informed of the benefits and risks of immunization or a certificate of completion of a vaccine educational module approved by the Oregon Health Authority.
For a medical exemption, a letter from a licensed physician is required, detailing the child's medical contraindications to vaccines.
Document the exemption by checking the appropriate boxes and signing the form in the designated section.

Are there any diseases that a child can be exempted from with this form?

Yes, parents or guardians can request that their child be exempted from any of the required immunizations listed on the form, including but not limited to Diphtheria/Tetanus/Pertussis, Polio, Varicella, and Measles/Mumps/Rubella, among others. The specific reasons for exemption can be noted, such as religious or philosophical beliefs.

What should be done if a child's immunization status changes?

If a child receives additional vaccinations or if there are changes to the child's immunization status, it is crucial to update the Oregon 53 05A form accordingly. The form must be re-signed each time an update is made to ensure that the information remains current and accurate.

Where should the completed Oregon 53 05A form be submitted?

Once completed, the Oregon 53 05A form should be submitted to the child’s school, preschool, child care, or home day care facility. These institutions are responsible for maintaining accurate immunization records and may share this information with the Oregon Health Authority or local public health departments upon request.

Common mistakes

When filling out the Oregon 53-05A Certificate of Immunization Status form, it's crucial to provide accurate and complete information to ensure your child meets the state's immunization requirements for school or child care attendance. However, errors can occur, and here are ten common mistakes to avoid:

Not completing the child's full name, birthdate, mailing address, and parents’ or guardians’ names and home telephone number. This information is essential for the school or child care facility to maintain accurate health records.
Failing to list the immunizations in the order they were received. The sequence of vaccinations is important for verifying that the immunization schedule has been properly followed.
Skimping on details for the vaccine doses, such as not filling in the month/day/year format accurately. This mistake can lead to confusion and inaccuracies in the child’s health record.
Omitting to check the box or provide details if the child has had chickenpox disease, which is an important piece of information that affects immunization requirements.
Forgetting to sign and date the form. The signature attests that the information is correct, and not signing it can invalidate the document.
Not using the shaded boxes appropriately for doses that are not routinely given but have been received by the child. These details are necessary for a complete immunization history.
Overlooking the necessity to update and re-sign the form whenever new information is added. This step is crucial for keeping immunization records current.
Neglecting to complete both sides of the form, particularly if the reverse side contains information on recommended vaccines or exemption details.
Mishandling the exemption process by not checking the appropriate box for medical or nonmedical exemptions or failing to attach the required documentation for these exemptions.
Ignoring the instructions for submitting a letter from a licensed physician in the case of a medical exemption or proof of immunity through history of disease or positive titer.

Ensuring the accurate completion of the Oregon 53-05A form helps to protect not only the health of your child but also that of their peers, by complying with state immunization laws and requirements. Carefully reviewing the form before submission can prevent these common errors.

Documents used along the form

When parents or guardians are navigating the process of ensuring their child meets the Oregon immunization requirements for school or daycare attendance, the Oregon Certificate of Immunization Status (Form 53-05A) becomes a key document. However, navigating the immunization process often involves more than just this form. Understanding additional forms and documents that may accompany or be required in conjunction with Form 53-05A can streamline this process, ensuring compliance and minimizing stress.

Medical Exemption Letter: For children who cannot be immunized due to medical reasons, a letter from a licensed physician is necessary. This document must detail the child's name, birth date, the medical condition contraindicating vaccines, the list of vaccines contraindicated, expected duration of the medical condition, and the physician's signature and contact information. It's a crucial document that formalizes the exemption for legal and educational purposes.
Proof of Varicella (Chickenpox) Disease Immunity: If a child has had chickenpox, a letter from a licensed physician stating the child's name, birth date, diagnosis, or laboratory evidence of immunity is required. This letter serves as an alternative to the varicella vaccine, evidencing the child's natural immunity to chickenpox.
Nonmedical Exemption Certificate: Oregon allows for exemptions based on religious or philosophical beliefs. To obtain this exemption, parents or guardians must first watch an educational module from the Oregon Health Authority or consult with a healthcare practitioner about the benefits and risks of immunization. Following this, they must submit a certificate of completion or a signed form by the healthcare practitioner, along with specifying the immunizations from which they are exempting their child.
Vaccine Education Module Certificate of Completion: When opting for a nonmedical exemption, the certificate that proves completion of the Oregon Health Authority’s educational module about vaccine benefits and risks is essential. This document confirms that parents or guardians have received crucial information to make an informed decision about immunizing their child.

Navigating the immunization requirements in Oregon is a multifaceted process that extends beyond submitting a single form. Having the correct additional documentation on hand ensures that a child’s health records are accurately reflected and complies with state laws, ensuring their access to education while upholding public health standards.

Similar forms

The California School Immunization Record shares a strong resemblance with the Oregon 53 05A form. Both are vital in ensuring children attending school are vaccinated according to state laws. They collect similar information, such as the child's name, birth date, and immunization dates for various vaccines. These forms also provide sections for medical or personal belief exemptions, requiring documentation or educational module completion for nonmedical exemptions. This supports public health efforts by aiming to prevent outbreaks of vaccine-preventable diseases within schools.

The Immunization Exemption Form for Texas parallels the Oregon document by offering an option for parents or guardians to exempt their child from required immunizations for medical reasons or because of conscientiously held beliefs. Like the Oregon 53 05A, the Texas form requires detailed information about the child's immunizations, or lack thereof, and includes provisions for documenting the reason for exemption. Both forms necessitate parental signatures to attest to the accuracy of the information provided and to acknowledge the possible exclusion from school attendance should an outbreak occur.

The Vaccination Waiver Form in Michigan is another parallel document, allowing parents to request waivers for their children from school and daycare vaccination requirements. Similar to Oregon's approach, Michigan's process involves education for parents about the benefits and risks of vaccines when seeking nonmedical exemptions. Both states aim to balance public health needs with individual freedoms by requiring informed consent and providing options for exemptions, albeit through slightly different administrative processes.

The < dem="Florida Certification of Immunization"> (Form DH 680) serves a similar purpose to the Oregon 53 05A by tracking a child's vaccination history and compliance with state school entry requirements. Both forms facilitate the collection of vaccination records for school-aged children and include provisions for documenting exemptions. However, Florida places a specific emphasis on electronic record-keeping, encouraging the use of its State Health Online Tracking System (SHOTS) for easier access and update of immunization records.

New York State Immunization Requirements for School Entrance/Attendance closely resembles the Oregon form in its function of ensuring children are vaccinated against specific diseases before attending school. Both require detailed recording of each vaccine dose and offer exemptions under certain conditions. The key similarity lies in their approach to public health, prioritizing the prevention of disease spread through comprehensive immunization documentation and compliance checks.

The Colorado Certificate of Immunization is designed similarly to the Oregon 53 05A form, mandating the recording of vaccine doses for school children and providing for medical and nonmedical exemptions. Both forms are integral to the states’ efforts to maintain high vaccination rates among students and minimize outbreaks of infectious diseases in educational settings. They require verification of the child’s immunization status or documentation supporting exemptions, reinforced by the authority of a healthcare professional or an educational module, respectively.

Dos and Don'ts

Filling out the Oregon 53 05A form is an essential process to comply with state requirements for school, preschool, child care, or home day care attendance. Paying careful attention to detail can ensure that this process is smooth and error-free. Below are ten dos and don'ts to consider when completing this form:

Do ensure that the child’s full name, birthdate, and current mailing address are accurately filled out. This basic information is crucial for identification and communication purposes.
Do list the vaccines in the order they were received. This keeps the immunization record organized and understandable for those reviewing the form.
Do check the required vaccines for your child’s age or grade with their school or daycare, as this can vary and is critical for compliance.
Do include dates in the month/day/year format for each vaccine dose administered. Accuracy in these dates is paramount for verifying the immunization schedule.
Do sign and date the form as a parent or guardian. This act is a declaration of the accuracy of the information provided and a requirement for submission.
Don't skip the recommended vaccines section. Though not required by law, these vaccinations are crucial for your child's health and well-being.
Don't forget to fill out both sides of the form. Each side contains important information that needs to be completed.
Don't overlook the need to resubmit documentation if applying for an exemption. Whether medical or nonmedical, this documentation is vital for the exemption process.
Don't hesitate to update the form and resign it if new immunizations are received after the initial submission. Keeping the record up-to-date is necessary.
Don't fail to provide a telephone number where parents or guardians can be reached. This information might be used for any follow-up or clarification regarding the form.

By following these guidelines, you can ensure that the Oregon 53 05A form is filled out correctly and completely, facilitating compliance with state immunization requirements.

Misconceptions

When it comes to navigating the landscape of immunization requirements for children in Oregon, the Oregon 53 05A form stands out as a vital document. However, several misconceptions surround its purpose, usage, and requirements. Let's clear the air about some of these common misunderstandings.

Only for School-Aged Children: While it's true the form is primarily used for school, preschool, and daycare admissions, it's also important for home daycare situations. Any childcare setting in Oregon may require this form, not just formal schooling environments.
Medical Exemptions are Rarely Granted: Some people believe that medical exemptions are next to impossible to get. However, exemptions can be obtained with appropriate documentation from a licensed physician detailing the medical reason why a child should not receive a vaccine.
Nonmedical Exemptions are Complicated: While it's important to be informed about the vaccines, obtaining a nonmedical exemption isn't as daunting as some might think. Parents or guardians simply need to submit documentation from a healthcare practitioner or complete an educational module approved by the Oregon Health Authority.
Every Vaccine is Required: The form clearly distinguishes between required vaccines and recommended ones. Not all vaccines listed are mandatory for childcare or school entry in Oregon, and provisions exist for exemptions under specific conditions.
History of Illness Doesn’t Count: If a child has already had a disease like chickenpox, some assume they must still get vaccinated. However, proof of immunity through documentation of the illness from a licensed physician can suffice in place of the vaccination.
One-Time Submission: Some believe once the form is submitted, it's done for good. In reality, the form should be updated with each new vaccine dose and resubmitted as needed, especially when changing schools or childcare facilities.
All Sections Must Be Completed for Submission: The key parts of the form are necessary, but not all sections apply to every child. For instance, exemptions or the section on additional recommended vaccines may not be relevant.
Physician Signature is Required: While a physician or health department staff can sign to verify vaccinations, the signature of a parent, guardian, or the student themselves (if over 15) is primarily what's needed to attest to the accuracy of the form.
No Flexibility in Vaccine Schedule: The form provides shaded boxes for doses that are not routinely given or may vary based on the child’s specific situation, implying there is some flexibility in how vaccine schedules can be completed.

Understanding the Oregon 53 05A form is crucial for ensuring children in Oregon are properly immunized or exempted according to state laws. Clearing up these misconceptions encourages informed decisions about vaccination and compliance with state requirements. When in doubt, consulting directly with the Oregon Health Authority or a healthcare provider can provide clarity and assurance.

Key takeaways

The Oregon 53 05A form is an essential document for ensuring children's adherence to the state's immunization requirements for school, preschool, child care, or home daycare attendance. Below are seven key takeaways regarding filling out and utilizing this form effectively:

The form collects vaccination information and exemption details on behalf of the Oregon Health Authority, Immunization Program, and may be shared with relevant authorities upon request.
Immunization history should be listed in the order that vaccines were received, ensuring an accurate and easily understood record.
For children who have received less common vaccinations, detailed in shaded boxes on the form, it is crucial to include these dates to maintain a comprehensive immunization record.
Obtaining either a medical or nonmedical exemption requires specific documentation. For medical exemptions, a letter from a licensed physician is necessary. Nonmedical exemptions require a certificate from a health care practitioner or completion of an approved vaccine educational module.
The form allows for the documentation of recommended vaccines not mandated by law but considered essential for a child's health, emphasizing the importance of a complete vaccination record.
A parent, guardian, or capable student of at least 15 years of age may sign the form to certify the accuracy of the information provided. This signature confirms the child's immunization history and any exemptions claimed.
It is mandatory to complete both sides of the form to ensure compliance with Oregon's immunization requirements. This includes providing contact information, vaccine details, exemption documentation, and updating the form as necessary.

In summary, the Oregon 53 05A form serves as a crucial tool for tracking immunization status, allowing for exemptions where appropriate, and ensuring children's eligibility for school or daycare participation in Oregon.

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