ࡱ > E V > ? @ A B C D bjbjss k 9 8 2 l A 4 @ : z z z B d 4 $ u '# l l " z z Z Z Z z z Z Z Z Z z bQg R Z 0 A Z # # Z # h D Z A # : Statement of Immunization Information According to the Day Nurseries Act and the Immunization of Schools Pupils Act each child entering a Licensed Child Care Program or enrolling into school is to be immunized as required by the Medical Officer of Health. This requirement can only be removed if you object to immunization for medical, conscience or religious reasons. The necessary exemption form can be obtained from the Health Unit or at www.hnhu.org FORMCHECKBOX Male Students Last Name Given Name FORMCHECKBOX FemaleDate of Birth Students Ontario Health Card Number FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Daycare/SchoolParent(s) or Guardian(s) NamesDoctor/ Health Care ProviderAddress Street Town Postal Code Home and Work PhoneCorrect dates are required (check with your doctor). Please complete dates and place a ( in the appropriate box. A copy of your childs immunization record (yellow card) if preferred. Date (year, month, day)DiphtheriaPertussis (whooping cough)TetanusPolioHaemophilus B Hib (meningitisRotavirusMeaslesMumpsRubellaHepatitis BVarivax (chicken pox)Prevnar (conjugate pneumococcal)Meningococcal conjugateRequired Ontario Immunization Schedule 2017 AgeVaccine2 monthsDiphtheria, Tetanus, Pertussis, Polio + Act HIB (Pediacel)4 monthsDiphtheria, Tetanus, Pertussis, Polio + Act HIB (Pediacel)6 monthsDiphtheria, Tetanus, Pertussis, Polio + Act HIB (Pediacel)After 1st birthdayMMR (measles, mumps, rubella) (MMR or Priorix)15 months MenC (Menjugate) and Varivax (chicken pox)18 monthsDiphtheria, Tetanus, Pertussis, Polio + Act HIB (Pediacel)4 6 yearsDiphtheria, Tetanus, Pertussis, Polio (Adacel-Polio)4 6 years 2nd MMR(measles, mumps, rubella).Can be given as MMRV-(measles, mumps, rubella, and varicella Priorix-Tetra)5 or 6 year old unimmunized child starting primary seriesDiptheria,Tetanus, Pertussis, Polio (InfanrixIPV) 12 years Menactra (Men ACWY) 14 16 years Tdap diphtheria, tetanus and pertussis (Adacel or Boostrix) Recommended Immunization (not required) AgePneumococcal ConjugateRotavirus (oral)Hep-BHPV2 months((4 months((1 year(12 13 years( 2 doses(2 doses Pediacel -, diphtheria, tetanus, pertussis, polio and haemophilus influenzae type B Quadracel- diphtheria, tetanus, pertussis and polio MMR measles, mumps and rubella Tdap- diphtheria, tetanus and accellular pertussis HPV Human Papillomavirus Vaccine MMRV- measles, mumps, rubella and varicella It is the parents responsibility to maintain a record of a childs immunization and to update the Haldimand-Norfolk Health unit as additional immunization is given. 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