School and Child Care Immunization

This page contains health care provider and staff resources on school and child care immunization requirements and reporting. We update it regularly to reflect changes from year to year.

If you’re a parent or guardian looking for information about school or child care requirements, visit our family-friendly immunization page in multiple languages.

Select any of the links below to jump to a specific topic.

Immunization Manual for Schools, Preschools and Child Care Facilities

Immunization Laws and Rules

Immunization Requirements

Certificate of Immunization Status (CIS)

Exemptions from Immunization Requirements - Certificate of Exemption (COE)

Conditional Status Attendance

Excluding Children Out-of-Compliance with Immunization Requirements

Outbreaks and Exclusion

Immunization Status Reporting

Immunization Information System School Module

Staff and Volunteer MMR Requirement

General Resources

Preschool and Child Care Resources

School K-12 Resources and Sample Letters

Vaccine Information

Program Webpages

Frequently Asked Questions

Immunization Manual for Schools, Preschools and Child Care Facilities

The Immunization Manual for Schools, Preschools, and Child Care Facilities helps staff who serve on the immunization frontline at schools, preschools, and child care facilities. You'll find helpful information and resources to answer questions about immunization requirements, process Certificates of Immunization Status, and complete status reports.

Immunization Laws and Rules

Immunization Requirements

According to the Washington Administrative Code WAC 246-105-030 and WAC 246-105-040 any child attending school, preschool, or child care in Washington State is required by law to be fully immunized (documentation of vaccination or proof of acquired immunity) against the following diseases at the ages and intervals in the CDC Advisory Committee on Immunization Practices immunization schedule:

Children entering school, child care, or other early learning programs are required to have certain vaccinations before they can start. These requirements are put into place to protect children, families, and communities from vaccine preventable diseases. Immunization requirements apply to all enrolled children, including those learning remotely.

The parent or guardian of a child must provide documentation of vaccination or proof of immunity to specific diseases. This requirement is based on the national Advisory Committee on Immunization Practices (ACIP) Immunization Schedule for school or child care registration and attendance. The specific diseases are listed in the chart below:

*required only until 5 years of age

IVRS - Individual Vaccine Requirements Summary for Schools and Child Care: Detailed clinical guidance on immunizations required for school and child care/preschool including catch-up schedules and exceptions

Child Care Requirements Charts

Child Care Requirements Charts

Children entering child care must get the required doses listed in this chart to be in compliance with immunization requirements. School-aged children (preschool - grade 12) in before and after-school programs must meet the immunization requirements for their grade in school. The requirements follow the national Advisory Committee on Immunization Practices (ACIP) Immunization Schedule.

To read the chart, find the child's age range and follow the row across to find the number of vaccine doses required by that age. For example, if a child is 6 ½ months old (not yet 7 months old), look at the row “By 5 months”. A 6 ½ month old child needs a total of 2 doses of DTaP vaccine. By the time the child reaches 7 months, they will need 3 total doses (look at the DTaP column and row “By 7 months”).

For Parents

Last revised December 2022 English (PDF) | ኣማርኛ - Amharic (PDF) | العربية - Arabic (PDF) | دری - Dari (PDF) | Español - Spanish (PDF) | 中文 - Chinese  (PDF) | Fosun Chuuk - Chuukese (PDF) | हिन्दी - Hindi (PDF)  | 한국어 - Korean (PDF) | Kajin Ṃajōḷ - Marshallese (PDF) | پښتو - Pashto (PDF) | Português - Portuguese (PDF) l ਪੰਜਾਬੀ - Punjabi (PDF)  | Русский - Russian (PDF) | Af-soomaali - Somali (PDF) | Tagalog (PDF) | Українська - Ukrainian  (PDF) | Tiếng Việt - Vietnamese (PDF) | 

For Child Care Providers 

Last revised December 2022  English (PDF) | Español - Spanish (PDF)

School Requirements Charts

School Requirements Charts

Students entering school (preschool - grade 12), attending in-person or on-line, must get the required doses listed in this chart to be in compliance with immunization requirements. The requirements follow the national CDC approved Advisory Committee on Immunization Practices (ACIP) Immunization Schedule with requirements specified by grade level.

To find the doses required, look at the row that includes the student's grade and the column for the required vaccine. For example, a student entering kindergarten needs two doses of MMR vaccine. The requirements and rules vary depending on the student's grade.

School Immunization Chart Changes for 2022-2023 (PDF)

For Parents

2024-2025 English (PDF) | Español - Spanish (PDF) | ኣማርኛ - Amharic (PDF) |  العربية - Arabic (PDF) | 中文 - Chinese (PDF) | Fosun Chuuk - Chuukese (PDF) | دری - Dari (PDF) | हिन्दी - Hindi (PDF) | 한국어 - Korean (PDF) | Kajin Ṃajōḷ - Marshallese (PDF) | پښتو - Pashto (PDF) | Português - Portuguese  (PDF)  l ਪੰਜਾਬੀ - Punjabi (PDF) l Русский - Russian (PDF) | Af-soomaali - Somali (PDF) | Tagalog (PDF) | Українська - Ukrainian (PDF) | Tiếng Việt - Vietnamese (PDF)

For School Staff

Certificate of Immunization Status (CIS)

Certificate of Immunization Status (CIS)

Before a child may attend a school or child care center, a parent or guardian must provide proof of the required immunizations or immunity using a department-approved Certificate of Immunization Status (CIS) form. The CIS may be printed from the WA Immunization Information System (IIS). Parents can also print a CIS by signing up with MyIR or complete the hardcopy form below. If the hardcopy form is used it must be medically verified by accuracy with either a health care provider signature or by attaching medical immunization records to the completed CIS so school or child care staff can verify it for accuracy.

School and Child Care Exemptions from Immunization Requirements

School and Child Care Exemptions from Immunization Requirements

Washington State Law allows parents or guardians to exempt their child from the school or childcare immunization requirements. Exemptions may be claimed for personal/philosophical, religious or medical reasons. Measles, mumps, and rubella may not be exempted for personal/philosophical reasons. To request an exemption a completed Certificate of Exemption must be submitted to the school or child care center. More information about exemptions is available in the Frequently Asked Questions document below.

Conditional Status Attendance

Children who are in the process of completing their required immunizations may remain in school or child care in a temporary conditional status.

Excluding Children Out-of-Compliance with Immunization Requirements

Excluding Children Out-of-Compliance with Immunization Requirements

By law, RCW 28A.210.120, it is the duty of the administrator of every public and private school and day care center to prohibit the further presence at the school or day care center for any and all purposes of each child for whom proof of immunization, certification of exemption, or proof of compliance with an approved schedule of immunization has not been provided in accordance with RCW 28A.210.080 and to continue to prohibit the child's presence until such proof of immunization, certification of exemption, or approved schedule has been provided. Students lacking immunization records who are covered under the federal McKinney-Vento Act may not be excluded. The exclusion of a child from a school shall be accomplished in accordance with rules of the Office of the Superintendent of Public Instruction, in consultation with the State Board of Health WAC 392-380-050 (Public schools) WAC 180-38-050 (Private schools).

Outbreaks and Exclusion

To control the spread of disease a local health officer may exclude children and staff in schools and child care facilities. WAC 246-110-020 It is encouraged for all for school and child care facilities to keep or have ready access to immunization records of staff as well as children should they be required in the event of an outbreak.

Immunization Status Reporting – Due Annually

School Module

The School Module is built into the Washington State Immunization Information System (IIS) for schools to track immunization records for students. The School Module page has more information about this free resource and how to use it.

Staff and Volunteer MMR Requirement

Staff and volunteers at a Child Care Center (including ECEAP and Head Start preschools) are required to provide specific immunization documentation to their facility (Chapter 43.216 RCW). They will need one of the following:

  • An immunization record showing they received the MMR vaccine.
  • Proof of immunity from measles through documentation of lab evidence of antibody titer.
  •  A health care provider’s attestation of the person’s history of measles sufficient to provide immunity against measles (the provider may consider CDC guidance regarding evidence of immunity including for those born before 1957).
  •  Written certification, signed by a health care practitioner, that the MMR vaccine is not advisable for the person.

For more information see the Employee and Volunteer MMR Requirement FAQs

General Resources

General Resources

Immunity Community

International Records

Preschool and Child Care Resources

Preschool and Child Care Resources

Parent Letters

Work Materials for Staff

Flyers, Graphics, and Social Media

School K-12 Resources and Sample Letters

School K-12 Resources and Sample Letters

Parent Letters

Work Materials for Staff

Flyers, Graphics, and Social Media

Vaccine Information

Program Webpages

Frequently Asked Questions

CIS - Certificate of Immunization Status
What is the Certificate of Immunization Status (CIS) form?

The CIS is a form that must be completed and turned into a child's school or child care to document the vaccinations required to document full immunity for children attending school or child care in Washington State.

Does the Certificate of Immunization Status (CIS) have to be turned in before my child can register for school?

Immunization paperwork must be turned in to the school or child care on or before the child's first day of attendance. The CIS is usually collected during the registration process.

What are the different Certificate of Immunization Status (CIS) options?

The CIS can be printed from the Immunization Information System (IIS) or a hardcopy CIS completed by hand:

  • Certificate of Immunization Status printed from the WA Immunization Information System (IIS). The CIS printed from the IIS shows the immunizations that health care providers and school nurses have documented in the IIS. It is medically verified by the IIS. No additional parent or health care provider verification signature is needed. There are two versions that print from the IIS:
    • Validated CIS
    • CIS printed from MyIR
  • Hardcopy Certificate of Immunization Status (CIS) completed by hand. It is verified as accurate by a signature from:
    • A health care provider, Or
    • A school nurse, administrator, child care health consultant or their designee after comparing the information on the CIS with medical vaccination records attached to the CIS
Where can I get a blank copy of the Certificate of Immunization Status (CIS)? How can I get copies of the CIS in other languages?

You can find the hard copy CIS in English and several other languages at: www.doh.wa.gov/SCCI

Can a health care provider send my child's records directly to the school, or do I have to turn them in?

Health care providers may send a medically verified Certificate of Immunization Status directly to the school or child care. This is allowable with verbal or written agreement from the parent or guardian under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Who can print the validated Certificate of Immunization Status (CIS) through the Immunization Information System (IIS)?

Health care providers, school and child care staff that have access to the IIS can print the validated CIS. Printing instructions (PDF). A CIS printed from the IIS is medically verified by the IIS. No additional parent or health care provider verification signature is needed.

What is the meaning of 'COMPLETE, NOT COMPLETE and CONDITIONAL' that appear on the Validated Certificate of Immunization Status (CIS) mean?

These terms indicate whether a child has completed or not completed the vaccinations needed to meet the immunization requirements for school or child care entry. The terms are defined as:

  • COMPLETE - A child has all the required immunizations for school or child care
  • NOT COMPLETE - A child has not completed all the required immunizations and is past the temporary conditional period
  • CONDITIONAL - A child is in the process of completing a series of vaccinations and is within the temporary conditional period. For a child to attend school in conditional status the parent or guardian must sign the conditional status acknowledgment on the CIS.
If a child has a "NOT COMPLETE" or "CONDITIONAL" status on their Certificate of Immunization Status (CIS), do I need to print a new CIS from the Immunization Information System (IIS) once the child receives the required immunizations?

It is not required that you print out a new CIS from the IIS. You may write in the immunization dates on the existing CIS and change the status by hand, or you can print a new CIS from the IIS, whichever you prefer.

The Certificate of Immunization Status (CIS) printed from MyIR is the older version. Can it still be used?

Yes. We are working with our software vendor to update the CIS in MyIR. In the meantime schools and child cares can accept this older version as a medically verified CIS. A CIS printed from MyIR is medically verified by the IIS. No additional parent or health care provider verification signature is needed. Please note that, unlike the validated CIS, the MyIR CIS prints vaccinations dates that are invalid if they were given outside of the required minimum ages and intervals. School and child care staff should carefully review the dates on the MyIR CIS to ensure the dates can be used to meet the immunization requirements.

What if a child does not have any immunization dates in the Immunization Information System (IIS)?

The immunization dates can be handwritten on the hardcopy Certificate of Immunization Status (CIS) . The information on the hardcopy CIS must be verified as accurate by a health care provider signature or medical vaccination records can be attached to the CIS and a school nurse, administrator, child care health consultant or their designee can compare the medical records with the information written on the CIS, and if accurate, can sign the verification signature.

What is considered a medical immunization record?

A "medical immunization record" means one of the following:

  • A medical record from a health care provider with their name and signature
  • An immunization record printed from a clinic or hospital's electronic health system
  • A medical record with an official health facility or provider logo/stamp
  • A document from another U.S. state or territorial immunization registry
  • An official lifetime immunization record with a unique health care provider/clinic stamp, or provider signature
  • For foreign students: a translated official immunization record such as an immigration form or lifetime immunization record from another country with a clinic or health care provider stamp.
What records are not considered a medical immunization record?

Immunization records that aren't medically verified include:

  • Dates given to a school orally or in writing without medical proof
  • Lifetime Immunization Records not filled out by a health care provider
  • Home vaccine lists, including baby books
  • A Certificate of Immunization Status completed by hand without a health care provider signature or without medical immunization records attached.
Can a parent staple the medical immunization record to the hardcopy Certificate of Immunization Status (CIS), or do the vaccination dates still need to be written on the CIS?

It is not acceptable to just attach an immunization record to a blank hardcopy CIS. The CIS must be filled out with the immunization information and verified for accuracy.

How can parents get help to fill out the Certificate of Immunization Status (CIS)?

Parents get help with a CIS in the following ways:

  • Parents can sign up for MyIR to view, download, and print their child's CIS. Steps on how to access MyIR
  • Parents can send an email to the Department of Health to request a CIS. The email is waiisrecords@doh.wa.gov
  • Parents can ask school and child care staff with access to the Immunization Information System (IIS) to print a validated CIS directly from the IIS. Schools may find it helpful to print the CIS during registration or other family events.
  • Parents can request a CIS printed from the IIS from their healthcare provider. Parents can also ask their healthcare provider to help them fill out the form.
How is varicella history and disease immunity verified on the Certificate of Immunization Status (CIS) form?

If entered into the Immunization Information System (IIS) varicella history and disease immunity by blood antibody titer will auto-populate on the CIS. Auto-populated varicella history and immunity by titer printed from the IIS are considered provider verified and will not need a healthcare provider signature.

If the hardcopy CIS is being used, varicella history and immunity by titer may be filled out and signed by a healthcare provider in the “Documentation of Disease Immunity” box found on the right side of the form.

If I print the Certificate of Immunization Status (CIS) from the Immunization Information System (IIS) and it shows that a student had a history of varicella (chickenpox), does a healthcare provider need to sign the CIS?

No. If varicella history is in the IIS, the "History of disease verified by the IIS" box will be checked in the varicella row on the CIS. This is considered provider verified and does not need a healthcare provider signature.

What are the options to verify a history of varicella disease?

Verification of varicella disease can happen in three ways:

  • Varicella disease history is verified by the Immunization Information System (IIS). If varicella history is in the IIS, the "History of disease verified by the IIS" box will be checked in the varicella row on the Certificate of Immunization Status (CIS).
  • Disease verified by a healthcare provider (HCP). The healthcare provider can check the verification box and sign the hardcopy CIS, or parents can provide a signed letter from the HCP to be kept with the CIS.
  • If school staff finds verification of varicella disease in the IIS, staff can add this information to the CIS.

Parent verification of chickenpox disease is no longer acceptable to meet the varicella immunization requirement.

I know that healthcare providers enter lab evidence of immunity in the Immunization Information System (IIS). Can I use this information to update the Certificate of Immunization Status (CIS) rather than getting a healthcare provider signature and copy of a lab report?

If lab evidence of immunity is documented in the IIS, it will print on the CIS under the “Positive Titer” column. This is a valid verification of immunity and a healthcare provider signature is not needed. A copy of the lab report is no longer required to accompany health care provider documentation of immunity by blood antibody titer.

Does a health care provider need to sign the Certificate of Immunization Status (CIS)?

A health care provider signature to medically verify vaccination dates, positive titers, or chickenpox history is not required if the CIS printed from the Immunization Information System (IIS) includes this information. This information is considered to be medically validated by the IIS.

A healthcare provider may sign a hardcopy CIS to verify that the immunization information is accurate. They can also document on the hardcopy CIS that the child has had varicella (chickenpox) disease or immunity by blood antibody titer test.

When does the CIS not need a health care provider signature?

If the CIS is printed directly from the Immunization Information System (IIS), either the validated CIS or the MyIR CIS, it does not need a healthcare provider signature verifying the information is accurate.

If parent turns in a hand-written CIS with attached medical vaccination records and the chief administrator, child care health consultant, school nurse or their designee signs the CIS verifying the information on the CIS matches the medical records then it does not need an additional healthcare provider signature verifying the information is accurate.

When the Certificate of Immunization Status (CIS) form is revised, do parents need to turn in an updated CIS for their children? Do I need to get a CIS from parents/guardians every year, even if they already have one on file?

Children who attend the same school or school district they attended prior to August 1, 2020, do not need to resubmit records. All new immunization records turned in on or after that date must be medically verified. Children attending a child care must turn in an updated medically verified CIS annually. When turning in a new CIS, the current version from the Immunization Information System, MyIR or the hardcopy form should be used.

Do schools using the Immunization Information System (IIS) School Module need a Certificate of Immunization Status (CIS) on file for each student?

No. School staff actively using the IIS School Module to do their immunization compliance work can verify that the student's immunizations are COMPLETE in the IIS and record the verification in the student's school record. If the immunizations are complete in the IIS then no CIS is required. Schools using the School Module only need a CIS for students who are in conditional status or if immunizations need to be added to the IIS to complete the record.

Can you explain the two places for a parent/guardian signature on the Certificate of Immunization Status (CIS)?

There are two places for parents to sign on the CIS:

  • One signature is required if a child is starting school or child care in conditional immunization status. For the child to be allowed to attend in conditional status the parent/guardian must acknowledge the conditional status rules and timelines with this signature.
  • The other signature is to give permission to add missing immunization information into the Immunization Information System (IIS). This allows school or child care staff with access to the Immunization Information System (IIS) School Module to add information needed to complete immunization information that may be missing in the IIS.
Do school or child care staff need parent consent every time they add immunizations to the Certificate of Immunization Status (CIS) obtained from the Immunization Information System (IIS)? How about immunizations from a medical immunization record?

No, school and child care staff don't need to get parent consent to update the CIS with additional immunizations from the IIS or a medical immunization record.

Both recommended and required vaccines for school and child care attendance are listed on the Certificate of Immunization Status (CIS). Does the CIS need to have all of the immunization dates, even if the vaccine is not required for school or child care attendance?

No, only immunization dates required for school and child care attendance must on the CIS. Additional recommended vaccines may be printed or written on the CIS to provide a more complete immunization record.

Can you explain the space (on the upper right) for staff signature on the Certificate of Immunization Status (CIS)?

This box is used by the school or child care staff person to document that they reviewed the CIS and indicate if a Certificate of Exemption is also on file for this child. Use of this box is optional.

Does a student with an exemption need to submit both a Certificate of Immunization Status (CIS) and a Certificate of Exemption (COE)?

It depends, if the COE exempts all of the required immunizations a CIS is not needed. If the COE only exempts some of the required immunizations, then both a CIS and COE need to be on file.

COE - Certificate of Exemption
What is the Certificate of Exemption (COE) form?

The COE form is used when a parent or guardian wants to exempt their child from one or more of the immunization requirements. The completed form must be turned into the school or child care.

Where can I get a copy of the COE? Are there copies of the COE in other languages? Can I get the Certificate of Exemption (COE) through the Immunization Information System (IIS)?

The COE in several languages is available on the School and Child Care immunization webpage: www.doh.wa.gov/SCCI. A COE cannot be printed from the IIS.

Does a student with an exemption need to submit both a Certificate of Immunization Status (CIS) and a Certificate of Exemption (COE)?

It depends, if the COE exempts all of the required immunizations a CIS is not needed. If the COE only exempts some of the required immunizations then both a CIS and COE need to be on file.

When the Certificate of Exemption (COE)is updated, does a student with a COE already on file need to submit the new COE?

No. The COE on file is valid for all exemptions other than personal/philosophical exemption for the measles, mumps and rubella immunization requirements. A new COE is not necessary for all other existing exemptions.

When is a new Certificate of Exemption (COE) effective? When should we start using it?

A revised COE is effective as soon as it is published on the DOH website. The date of publication is on the bottom of the form. Parents should use the most current COE to request any new exemption from the immunization requirements.

What kinds of exemptions are available for parents who want to exempt their child from the school or child care immunization requirements?

There are four different types of exemptions:

Medical Exemption: A health care practitioner may grant a medical exemption to a vaccine required by rule of the state board of health only if in his or her judgment, the vaccine is not advisable for the child. When it is determined that this particular vaccine is no longer contraindicated, the child will be required to have the vaccine.

Philosophical/Personal Exemption: To be used when the parent/guardian has a personal or philosophical objection to the immunization of the child. A philosophical/personal exemption may not be used to exempt a child from the measles, mumps or rubella vaccine requirements (effective July 28, 2019).

Religious Exemption: To be used when the parent/guardian has a religious belief that is contrary to the required immunization.

Religious Membership Exemption: To be used when the parent/guardian affirms membership in a church or religious body that does not allow them to take their child for medical treatment from a health care practitioner (MD, DO, NP, PA. ARNP). Because it is against their religious beliefs to get medical treatment from a health care practitioner this exemption does not require a health care practitioner signature.; RCW 28A.210.090.

What kinds of exemptions are available for parents who want to exempt their child from the measles, mumps and rubella (MMR) school or child care immunization requirements?

There are three types of exemptions that can be claimed with a completed Certificate of Exemption for MMR:

  • Medical Exemption - signed by both the parent and health care practitioner
  • Religious Exemption - signed by both the parent and health care practitioner
  • Religious Membership - signed by the parent. This exemption type is only used when the religious belief does not allow for medical treatment by a health care practitioner, therefore no health care practitioner signature is required.

Personal or philosophical exemptions are not allowed for MMR. RCW 28A.210.090

For students who had a personal exemption for measles, mumps and rubella (MMR) on file before the law changed in 2019, will those exemptions continue to be accepted, or will those exemptions be void and the student will need to get the MMR vaccine or another type of exemption?

The law did not include a grandfathering or exclusion clause for students who had personal exemptions for the measles, mumps or rubella immunization requirements in place before the law changed. As of July 28, 2019 any existing personal exemptions to the MMR immunization requirements were voided.

How do I know if my child qualifies for a medical exemption?

Your child's healthcare provider will determine if they need to be temporarily or permanently exempted from receiving a vaccine for a medical reason. Medical contraindications and precautions to vaccination are outlined in the Advisory Committee on Immunization Practices' (ACIP) recommendations and guidelines published by the Centers for Disease Control and Prevention. Medical contraindications to vaccination are rare.

Does a temporary medical exemption need to have an expiration date?

Yes, health care practitioners must put the date that the temporary exemption ends on the Certificate of Exemption. School, preschool, or child care staff should monitor temporary exemptions. When the temporary exemption ends the child can be in conditional status for up to 30 days in order to get the missing immunization or another exemption.

What is the difference between a religious and a religious membership exemption?

Religious Exemption: To be used when the parent/guardian has a religious belief that is contrary to the required immunization. This requires the signature of a health care practitioner that they have provided the parent with information about the benefits and risks of immunization for the child.

Religious Membership Exemption: To be used when the parent/guardian affirms membership in a church or religious body that does not allow them to take their child for medical treatment from a health care practitioner (MD, DO, NP, PA. ARNP). This exemption does not need a healthcare practitioner signature. If the parent or guardian has a religious objection to the vaccine but takes their child to see a health care practitioner for things like illness and injury care this is not the appropriate exemption. They should use the Religious Exemption area of the COE which must have a healthcare practitioner signature. RCW 28A.210.090.

How do health care practitioners, school or child care staff determine if a religious or religious membership exemption is based on actual religious beliefs?

It is not recommended that school or child care staff attempt to verify the religious beliefs of a parent/guardian requesting a religious or religious membership exemption. A completed Certificate of Exemption is all that is required. The role of the health care practitioner is to provide information to the parent/guardian. The health care practitioner's signature indicates that they have provided the information, not that they have assessed the parent's religious beliefs.

What if I think a parent who is asking for a religious membership exemption takes the child in for medical treatment?

If the child receives medical treatment for things other than immunizations the religious membership exemption is not the appropriate type of exemption. Ask the parent if the child sees a health care provider for injury or illness care. If the parent or guardian says yes, then another exemption which requires a health care practitioner signature should be used instead.

When completing medical exemption section of the Certificate of Exemption (COE) form, does the health care practitioner need to identify the reason why the vaccine is not advisable for the child?

It is not required to provide the reason for granting the medical exemption. This information is not requested on the Certificate of Exemption form.

Does the Certificate of Exemption (COE) need to be signed by a healthcare practitioner?

In most cases, yes. Parents or guardians requesting a medical, philosophical, or religious exemption must have the signature of a health care practitioner (MD, DO, ND, ARNP, PA) licensed in Washington state confirming that they provided the parent with information about the benefits and risks of immunizations. A practitioner may also write and sign a letter containing the same information instead of signing the COE. This letter must be attached to the parent signed COE. If granting a medical exemption, the practitioner must complete the medical exemption section of the COE.

A health care practitioner does not need to sign the COE if the parent claims a Religious Membership exemption. This exemption states that the parent's religious beliefs do not allow medical treatment of their child by a health care practitioner. This exemption does not require a health care practitioner signature. Parents/guardians who have a religious objection to vaccination but whose children obtain care from health care practitioners need to use the religious exemption which requires a health care practitioner signature.

Which providers are allowed to sign the Certificate of Exemption (COE) ?

Only a health care practitioner can sign the COE. A healthcare practitioner is defined as a physician (M.D.), physician assistant (P.A.), osteopath (D.O.), naturopath (N.D.), or advanced registered nurse practitioner (A.R.N.P.) licensed in Washington state. For more details, see Revised Code of Washington (RCW) 28A.210.090.

Do health care practitioners face any liability for signing the Certificate of Exemption (COE)?

A health care practitioner who, in good faith, signs the statement that they have provided the parent with information about the benefits and risks of immunization for the child, are immune from civil liability for providing the signature. For more details, see Revised Code of Washington (RCW) 28A.210.090.

If a family has an out-of-state exemption on file signed by a MD, then do they still need to have a Washington State Certificate of Exemption (COE)? Can a school or child care provider accept a Washington state COE signed by a health care provider in another state or country?

A certificate from another state cannot be used to exempt a student from the WA state immunization requirements. The Washington state Certificate of Exemption form must be used and the health care practitioner (MD, DO, ND, and ARNP, PA) who signs it must be licensed in Washington state. For more information, see the Revised Code of Washington (RCW) 28A.210.090.

Is a health care practitioner required to sign a religious exemption form, or can they refuse?

This is not addressed in state immunization law. A health care practitioner should speak with their professional organization or discuss with their own legal counsel. The role of the practitioner is to provide information and their signature indicates they have provided the information, not that they have assessed or agree with the parent's religious beliefs.

Is a health care practitioner legally allowed to request proof of religion/church membership if they are being asked to sign a religious exemption?

The role of the health care practitioner is to provide information to the parent about the benefits and risks of vaccination. Their signature indicates they have provided the information, not that they have assessed the validity of the person's religious beliefs. There is nothing requiring the provider to check for documentation. If a provider feels they want to incorporate this into their practice, they should discuss with their professional organization or their own legal counsel.

Can a parent who is a health care practitioner licensed in WA sign the health care practitioner declaration on the Certificate of Exemption (COE) for their own child?

Only a physician, osteopath, naturopath, physician assistant, or advanced registered nurse practitioner licensed in Washington state may sign the WA COE. If the parent is one of the qualified health care practitioners listed in the law (RCW 28A.210.090), it is up to that practitioner's own best judgment, based on their individual legal, ethical, medical, and professional obligations.

Does a student without any exemptions need a copy of a Certificate of Exemption (COE) in her or his file?

No. Students must have a completed COE on file in their record only if they have an exemption to one or more of the immunization requirements.

What should I do if a Certificate of Exemption (COE) has both personal and medical exemptions listed for the same immunization requirement/disease?

If a parent turns in, or during record review you discover, a COE that has been improperly filled out, return it to the parent and let them know a properly completed COE is needed for the exemption to be valid. In this case, inform the parent that they may only have one type of exemption per disease immunization requirement.

Does a Certificate of Exemption (COE) expire? Does a COE need to be renewed annually?

The only type of COE with an expiration date is a COE with a temporary medical exemption. The COE does not need to be renewed annually. Once a COE is filled out, it can be used for the length of the student's Washington state school career, including school transfers. If parent's request changes to the COE a new form must be completed.

What are the options for a health care practitioner to document that they have provided the parent information about the benefits and risks of vaccination needed for a personal or religious exemption?

A health care practitioner can sign the health care practitioner declaration on the Certificate of Exemption form or they can give the parent a letter that includes the name and birthdate of the child, the practitioner's printed name, Washington license number, signature, and date of signature stating that they have “provided the parent/guardian information about the benefits and risks of immunization to the child”. If the parent/guardian education is documented in a letter, it must be attached to a parent/guardian-signed COE before being turned into the school or child care.  

I see that a healthcare provider entered a contraindication of “Parent or Patient Refusal, Personal or Religious” in the Immunization Information System (IIS) for a patient. Can I use this information to document a personal or religious exemption for a student rather than have the provider sign the Certificate of Exemption (COE)?

No, documentation of a refusal in the IIS means the parent or patient refused a vaccine offered to them during a provider visit. It does not mean that the parent or patient requested an exemption from the school or child care immunization requirements. It also does not document that a health care practitioner (MD, DO, ND, and ARNP, PA) discussed the benefits and risks of immunizations with the parent. The IIS does not have a place to document that information. Parents requesting an exemption from the immunization requirements must turn in a completed COE to the school or child care.

I have a lot of questions about exemptions and how to fill out the Certificate of Exemption (COE). Where can I get more information?

For more information please email: OICPSchools@doh.wa.gov

Conditional Status Attendance
What does conditional status mean?

On or before the first day of school or child care attendance parents/guardians are required to provide proof of either, full immunization, a certificate of exemption, or the initiation of and compliance with a schedule of immunization for their child, (per RCW 28A.210-080). Children can enter and stay in school or child care in conditional status if they are catching up on the vaccines required to document immunity for school or child care entry. Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. Conditional status allows them to attend school or child care while waiting for their next vaccine dose according to the national immunization catch-up schedule. When the next vaccine dose comes due they have 30 calendar days to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the vaccines needed to document full immunity are completed.

What conditions must be met for a child to attend school or child care in conditional status?

To attend school or child care in Conditional Status the following conditions must be met (WAC 246-105-050):

  • The parent/guardian must sign the Conditional Status statement on the Certificate of Immunization Status form to acknowledge their child is attending school or child care in conditional status with the associated timelines.
  • Children must be up to date on their immunizations, having received all of the vaccine doses they are eligible to receive before they can start school or child care.
  • When the next catch-up vaccine dose comes due, the parent or guardian must turn in documentation within 30 days of the vaccination due date. Valid documentation includes medical records showing vaccination, evidence of immunity to the disease in question, or a completed Certificate of Exemption (COE) form.
What does "any the vaccine doses they are eligible to receive" mean?

Children are due for different vaccines depending on their age. "Any doses the child is eligible to receive" means all of the required vaccine doses the child is old enough to receive and the recommended time interval from the previous dose of that vaccine has been met according to the national immunization catch-up schedule. For example:

  • A child entering kindergarten has had no vaccines:
    • The child must get one dose of each of the required vaccines (Hepatitis B, DTaP, IPV, MMR and Varicella) before starting school. They are then in conditional status until the next vaccine is due plus 30 calendar days to turn in documentation that they have gotten the vaccine. Conditional status then continues as described until all of the vaccine series are complete.
  • A child entering kindergarten has had all vaccines except MMR dose 2. MMR dose one was administered 1 week before the start of school:
    • The child can start school in conditional status for 3 weeks (waiting for MMR dose 2 minimum valid date) plus an additional 30 calendar days in which to get the dose and turn in documentation to the school.
  • A child entering kindergarten has all of the early childhood vaccines but is missing their age 4 - 6yr vaccines required for kindergarten entry:
    • The child must get the missing DTaP, IPV, MMR and varicella before starting school. Then they have completed the vaccinations needed for their grade. They do not need conditional status attendance.
  • A student entering 7th grade has not had their required Tdap booster:
    • The student must get the Tdap vaccine before starting school. Then they have completed the vaccinations needed for their grade. They do not need conditional status attendance.
What happens if documentation is not turned in within the 30 day time period?

If the 30 day conditional period, after the next vaccine dose comes due, expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes medical records showing vaccination, evidence of immunity to the disease in question, or a completed certificate of exemption (COE) form.

When does a child enter conditional status and for how long?

The most common scenario occurs when a child arrives on their first day of school missing required immunizations. The child must get any of the doses they are eligible to receive before starting school. If additional doses are needed to complete the vaccine series then they can start school on the condition that they continue to get the remaining doses based on the national immunization catch-up schedule. They must get remaining doses within 30 calendar days following the recommended date of the next dose needed according to the national schedule. A child also enters conditional status when a temporary medical exemption expires. In this case, the child has 30 calendar days from the expiration date of the medical exemption to get the missing immunization(s) or another exemption.

Who grants conditional status?

The school or child care staff determine if the conditions for conditional status have been met.

Does conditional status only apply to students attending a new school or district?

No, conditional status applies to any child without an exemption attending school or child care who is missing immunizations and waiting for the recommended date of the next vaccine dose needed according to the national schedule.

How do the conditional status rules apply to children in military families?

Children of active-duty military parents or guardians must turn in documentation of immunization status on or before the first day of attendance. If they need additional vaccine doses to meet state requirements, they have 30 days from enrollment to do so.

Does conditional status apply to children in child care?

Licensed child day care centers must follow the immunization requirement laws and rules. This includes all public and private child cares licensed by the Department of Children, Youth, and Families to provide early childhood education and early learning services for a group of children for periods of less than twenty-four hours.

How do the rules apply to children who are homeless or in foster care?

There is an exception for students who are considered homeless according to the McKinney-Vento Act or in foster care. They must be allowed to enroll, attend classes, and participate fully. They cannot be excluded for being out of compliance with the immunization requirements. School and child care staff should work with the Homeless Liaison or Foster Care Caseworker to bring the child into compliance. Every foster child/youth in out-of-home placement should receive an EPSDT/Well-Child examination, which includes immunizations if needed, within 30 days of entering any foster or relative placement. For more information see the Immunization Manual for Schools, Preschools, and Child Care Facilities.

What is the WA Administrative Code (WAC) that talks about conditional status?

It is: WAC 246-105-020, WAC 246-105-050 and WAC 246-105-060

Is there a requirement to make more than one parent contact by letter or phone to let them know their child is in conditional status, or just the notice of exclusion required in RCW 28A.210.120?

No additional requirements exist beyond the RCW and WAC procedures for excluding students. Even though not specified in the law, it is best practice to send a written notice to parents about the student's conditional status.

Does DOH have sample letters for students in conditional status or who need to be excluded?

Sample letters are available in the Conditional Status Attendance and Excluding Children Out-of-Compliance with Immunization Requirements sections of the School and Child Care Immunization page www.doh.wa.gov/SCCI.

Disease Outbreaks
Why would students or staff be excluded from school during disease outbreaks?
Excluding people who were potentially exposed or known to be susceptible to a disease can help stop an outbreak for some diseases.
Why is exclusion done for some diseases and not for others?
Exclusion is thought to decrease the spread of some diseases more than others. The local health officer makes the determination if excluding people susceptible to the disease during an outbreak is warranted.
Who decides if students or staff will be excluded in an outbreak situation?

The County's local health officer has the authority to exclude students, staff, and volunteers in schools or childcare centers if they are infectious, exposed, or susceptible to the disease. See WAC 246-110-020 for more information.

What documentation is needed in the event of an outbreak at a school or child care?
The local health officer will determine what documentation is acceptable. As an example, according to the Centers for Disease Control and Prevention acceptable documentation of measles immunity includes one of the following; 1) date of birth before 1957. 2) record of age-appropriate measles vaccination with a live measles virus-containing vaccine. This means two doses for anyone 4 years and older, or one dose for adults, verified by a licensed health care provider. 3) A letter from a licensed health care provider documenting infection with and full recovery from previous measles illness. 4) A letter from a licensed health care provider that confirms a blood test showing measles immunity. Proof of immunity should be prior to a disease exposure. Those staff and students who receive vaccination after exposure may still need to be excluded.
How long can students and staff be excluded?
This will be determined by the local health officer. The student and staff exclusion time depends on the exposure period and the incubation time of the specific disease. As an example, exclusion for measles lasts until 21 days have passed since the date of last known possible exposure. This is in accordance with WAC 246-105-040. This exclusion time may be extended if another case occurs.
Are staff required to use their sick leave or vacation if they are excluded?
This would depend on the child care, district or school's policy and procedures.
Employee and Volunteer MMR Requirement
What is the MMR requirement for child care staff and volunteers?

The law requires all child care staff and volunteers to have documentation of vaccination with the MMR (measles, mumps and rubella) vaccine or have evidence of immunity to measles.

Do child care employees and volunteers have to provide documentation of vaccination status to the state or to their employer?

Child care employees and volunteers have to provide documentation to their employer and it will be kept onsite in their personnel file. It will be checked by child care licensors at their monitoring visits. It may also be accessed by the local health officer if there is an outbreak of measles or other vaccine-preventable disease. For further questions on this topic, contact the Department of Children, Youth, and Families.

How does a child care staff person or volunteer comply with the requirement?

The law requires that staff and volunteers at licensed child care facilities provide one of these options:

  • Immunization records showing they have received the MMR vaccine.
  • Proof of immunity to measles through documented lab evidence of antibody titer.
  • A healthcare provider's attestation of the person's history of measles sufficient to provide immunity against measles. (The provider may consider CDC guidance for evidence of immunity, including for those born before 1957.)
  • Written certification, signed by a Washington-licensed MD, ND, DO, ARNP, or PA, that the MMR vaccine is not advisable for that person.
What child care providers have to comply with the staff and volunteer MMR law?

All public and private child cares licensed to provide early childhood education and early learning services for a group of children for periods of less than twenty-four hours. This portion of the law will be implemented by the state Department of Children, Youth and Families (DCYF). The new law adds a new section to RCW 43.216, which DCYF has authority over.

Will K-12 school employees and volunteers have to provide documentation of MMR vaccination status to the state or to their employer?

The law does not include language requiring school staff and volunteers to provide documentation of immunity to MMR disease unless they are supervising children in an early learning program. However, the Department of Health encourages anyone who is around children to be immunized against contagious diseases and up to date with any recommended vaccines. For more information about vaccines recommended for adults, see page 28 of the Immunization Manual for Schools, Preschools, and Child Care Facilities (PDF).

If child care staff or volunteers think they had the MMR vaccine in the past and can't find their records is it safe to get another one?

In most cases, the Centers for Disease Control and Prevention recommends repeating the vaccine if there is no medically verified record that the shot was given. If that is not an option, a titer test is available to check whether you are immune to measles. Consult with your healthcare provider for the best option for you.

If an employee or volunteer was vaccinated for measles but they did not get the MMR vaccine, is that sufficient, or do they need to get the full MMR vaccine?

If they are providing documentation of being vaccinated, it needs to include vaccination against all three diseases-measles, mumps and rubella. If they are providing lab evidence of immunity (also known as a blood test or titer), it only needs to be for measles.

Can a child care staff person or volunteer turn in an exemption to the requirement?

Staff and volunteers may not be exempted from the requirement to provide documentation of immunity for personal and religious reasons. Only written certification signed by a health care practitioner, licensed in WA State, (medical doctor (MD), naturopathic doctor (ND), osteopathic doctor (DO), advanced registered nurse practitioner (ARNP) or a physician's assistant (PA)) that the measles, mumps, and rubella vaccine is, in the practitioner's judgment, not advisable for the person can be used instead of the required documentation of immunity.

What if child care staff or volunteers need more time to obtain and provide the needed records?

The child care center may allow a person to be employed or volunteer on the premises for up to thirty calendar days if they sign a written statement that they have received the MMR vaccine or are immune from measles, but require additional time to obtain and provide the records.

Does the law pertain to after-school programs at child care centers (like the YMCA)?

Yes. This applies to all licensed child care settings.

What about a private school that operates a child care center on site? Does the law apply to Kindergarten through 5th grade teachers since they are in the same facility and/or may have some interaction with the child care children?

The law applies to all staff and volunteers of licensed child day care centers, including “nonemployees who provide care and supervision to children at the child day care center.” If that applies to those teachers or other staff or volunteers, then yes. The Department of Health encourages anyone who is around children to be immunized against contagious diseases and up to date with any recommended vaccines.

Does the law apply to independent contractors? Examples include early intervention providers visiting campus, home visitors, social workers, speech pathologists or hired photographers.

Independent contractors are not considered employees or volunteers, so the new law does not apply to them. However, an agency can encourage independent contractors to keep up to date on their immunizations

Does the law apply to family home care sites?

No, but family home care centers are allowed to set their own policies for their workers, volunteers, and attendees. In the event of a vaccine-preventable disease outbreak like the measles, the local health officer can require the family home care site to provide immunization status information for all employees and attendees. If no documentation is provided, the health officer can require individuals to stay away from the site.

I'm a child care worker/volunteer and need to get my MMR vaccine. Will I have to pay for it?

Most people can get the vaccine at no cost or low cost. MMR vaccine is covered by most insurance companies, including Medicare and Apple Health (Medicaid). The state provides vaccine at no cost to those younger than 19. Find out more about coverage for adult vaccines here.

General
How can I access my immunization record in the state registry?

This website has information about how to access your vaccination records in the state registry called the WA Immunization Information System, including accessing MyIR.

What immunization documentation does a school or child care need so a child can attend?

Children are required to have documentation of full immunization or an exemption when they start school or child care. A Certificate of Immunization Status (CIS) form showing that the student is fully immunized or is catching-up with the vaccine series, or a Certificate of Exemption (COE) form must be turned in on or before the student's first day of attendance (per RCW 28A.210-080). There is an exception for students who are considered homeless according to the McKinney-Vento Act or in foster care. They must be allowed to enroll, attend classes, and participate fully. They cannot be excluded for being out of compliance with the immunization requirements. School and child care staff should work with the Homeless Liaison or Foster Care Caseworker to bring the child into compliance.

Do the immunization requirements apply to both public and private schools?
Yes, the immunization laws apply to both public and private school students.
Do students who attend online school or other alternative programs need to meet the immunization requirements?

Students enrolled at a public or private school participating in alternative school programs must follow the same immunization rules as all other students. They need a completed Certificate of Immunization Status (CIS) and/or Certificate of Exemption (COE) on file at the school or district program. Find more information in the Immunization Manual for Schools, Preschools, and Child Cares.

Do students with an IEP (Individualized Education Program) have different immunization requirements than those without?

There are no special provisions or exceptions for students being served under special education. Immunization compliance for school attendance is outlined in state law. Schools are encouraged to work with families to ensure that students continue to receive necessary services identified in their IEP.

Do international students need to follow the immunization requirements?

International students, even those only attending school for a short time, must comply with the immunization requirements and have a CIS and/or Certificate of Exemption (COE) on file at the school.

How do the immunization requirements affect colleges and universities?

Washington has no state law requiring immunizations for post-high school education institutions. Each college or university has their own policy regarding immunization requirements for students. Check with your college or university to find out if they have immunization requirements. Many of them explain their immunization policy on their website.

How can I access my child's immunization record in the state registry?

This website has information about how to access your child's vaccination records in the state registry called the WA Immunization Information System, including accessing MyIR.

Is there a way to request vaccination records from other states?

This Centers for Disease Control and Prevention website has contact information for each of the US immunization registries.

Why don't I/my child have a state immunization record?

The Washington Immunization Information System (WA IIS) started about 25 years ago and it is used by almost all providers who give childhood vaccines. It is specific to Washington state. If you are unable to find the record you are looking for, please check with your healthcare provider to see if they are putting information into the WA IIS. If you have medically verified vaccination records from another state or country or from before the system was in use, bring those records to your healthcare provider. Medically verified records can be added to the WA IIS by your healthcare provider so it will be easier to find them in the future.

Does my child or do I have to get a vaccine again if I can't find the record?

In most cases, the Centers for Disease Control and Prevention recommends repeating the vaccine if there is no medically verified record that the vaccine was given. If that is not an option, a titer test may be available to check whether you are immune to the disease. Consult with your healthcare provider for the best option for you.

What is an antibody titer test?

An antibody titer test is a lab test (blood draw) that can check if an individual has immunity to a disease. Not all vaccine-preventable diseases have a titer available. If you feel you or your child are already immune to the disease through having the disease or through vaccination, your healthcare provider can discuss if a titer test is the right option for you. Depending on the disease, the provider may recommend getting the vaccination instead. Check with your insurance provider to find out whether the cost of a titer is covered by insurance.

Which diseases can have immunity documented by blood antibody titers?

All diseases can have immunity by blood antibody tests documented by a health care provider (HCP) except for pertussis, pneumococcal (PCV) and Haemophilus influenzae type b (Hib). The HCP must state on the CIS or in a letter that the child has blood antibody titer levels sufficient for immunity. If the HCP is documenting immunity to polio, blood antibody titer testing must show immunity for all three types of polioviruses.

Are there risks if I decide not to vaccinate my child?

It's easy to overlook the benefits of vaccination when we rarely see people sick with some of the diseases that vaccines prevent. But the decision not to immunize a child involves risk. Choosing not to immunize puts the child and others at risk of getting a dangerous disease that could be deadly. Immunization is the single most important way parents can protect their children against serious diseases, and it's reasonable to ask questions about it. If you have questions or concerns about immunizations, it is important to talk with your child's healthcare provider. You can also learn more about vaccination and the risks and benefits of both choices in Plain Talk About Childhood Immunization (PDF).

Where can parents go for current information on immunization?

A good place for parents and guardians to find trusted and reliable information on immunizations is www.doh.wa.gov/immunization.

I have questions about the school and child care immunization rules. Whom do I contact?

If you have questions about the immunization requirements you can email OICPSchools@doh.wa.gov.

I want to talk to the State Board of Health about school immunization rules. Whom do I contact?

Find the Board of Health's contact information on their website, sboh.wa.gov.

I want to talk to DCYF about child care immunization rules. Whom do I contact?

If you are a parent with questions about immunizations in your child care center, contact your licensor. For general child care questions, contact Jennifer Helseth at Jennifer.helseth@dcyf.wa.gov.

Can a private school set immunization policies that are stricter than the state's requirements?

If the administration of a private school would like to set immunization policies stricter than the state's requirements, they should consult with their legal counsel. The Department of Health cannot give legal advice. Find state immunization laws within the Revised Code of Washington (RCW) sections 28A.210.060, 28A.210.080, and 28A.210.090.

Can a private child care set immunization policies that are stricter than the state's requirements?

For questions about child care requirements, please contact Jennifer Helseth of the Department of Children, Youth, and Families at Jennifer.Helseth@dcyf.wa.gov.