Form no 121 certificate of immunization compliance 2001-2026

1. Click ‘Get Form’ to open the Certificate of Immunization Compliance (form 121) in the editor.
2. Begin by entering the child's name, Social Security Number, and birthdate in the designated fields at the top of the form.
3. Fill in the parent's name and address, ensuring all details are accurate for proper record-keeping.
4. In the vaccine section, record each dose given for vaccines such as Prevnar, Varicella, DTaP/DT/Td, Hib, Polio, MMR, and Hep B. Use the provided checkboxes to indicate if there is a prior history of chicken pox.
5. Select one box indicating whether the individual meets immunization requirements for daycare or school entry. Ensure you provide dates for serological confirmation if applicable.
6. Finally, have a physician or health provider sign and date the form to validate it before submission.

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