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Free Oregon 53 05A Form

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The Oregon 53 05A form, officially known as the Certificate of Immunization Status, plays a crucial role in ensuring that children are properly immunized before attending school, preschool, child care, or home day care. Under Oregon law, parents or guardians must provide proof of immunization or sign an exemption form, thereby safeguarding public health within the community. This form collects essential information, including the child's full name, birth date, mailing address, and the names of parents or guardians, as well as their contact details. It requires a detailed record of immunizations received, listed chronologically, and includes spaces for various vaccines such as Diphtheria, Tetanus, Pertussis (DTaP), Polio, and Measles, Mumps, Rubella (MMR). In addition to required vaccines, the form also outlines recommended vaccines, which, while not mandatory, are advised for children's health. The form accommodates both medical and nonmedical exemptions, allowing parents to decline certain vaccinations under specific conditions. To ensure accuracy, the form must be signed by a parent, guardian, or qualified medical professional, affirming the authenticity of the immunization history. Understanding the intricacies of this form is essential for parents navigating the requirements for their children's health and school attendance.

Common mistakes

  1. Incomplete Personal Information: Many individuals fail to provide complete details for the child, such as the last name, first name, middle initial, or birthdate. Missing any of these essential elements can lead to delays in processing or even rejection of the form.

  2. Incorrect Vaccine Dates: It is crucial to list the vaccines in the exact order they were received. Some people mistakenly enter the doses out of sequence or omit doses altogether, which can create confusion regarding the child's immunization history.

  3. Neglecting to Sign the Form: A common oversight is forgetting to sign the form. The signature serves as a verification of the information provided. Without it, the form may be considered invalid, resulting in the need for resubmission.

  4. Ignoring Exemption Requirements: When applying for a nonmedical exemption, individuals often overlook the need to attach the required documentation. Failing to provide a health care practitioner’s certificate or the educational module completion certificate can lead to automatic denial of the exemption request.

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Listed Questions and Answers

What is the Oregon 53 05A form?

The Oregon 53 05A form, also known as the Certificate of Immunization Status, is a document required by Oregon law. It serves to provide proof of a child's immunization history before they can attend school, preschool, child care, or home day care. The form collects essential information about the child’s vaccinations and may be shared with local health authorities upon request.

Who needs to fill out this form?

This form must be completed for any child who is enrolling in school, preschool, child care, or home day care in Oregon. Parents or guardians are responsible for providing accurate vaccination records or signing for an exemption if applicable.

What information is required on the form?

The form requires the following information:

  • Child's full name and birthdate
  • Mailing address
  • Parents’ or guardians’ names and contact number
  • Details of each vaccine received, including dates

It is crucial to list the vaccines in the order they were administered.

What if my child has not received all required vaccinations?

If your child has not received all required vaccinations, you may request a medical or nonmedical exemption. For a nonmedical exemption, you must provide documentation that discusses the benefits and risks of immunizations, or complete a vaccine educational module approved by the Oregon Health Authority.

How do I submit the form?

Once completed, the form should be submitted to your child’s school or child care facility. Ensure that both sides of the form are filled out and signed appropriately. Keep a copy for your records.

What happens if I do not submit the form?

Failure to submit the Oregon 53 05A form may result in your child being excluded from school or child care until the required immunization documentation is provided. It is essential to comply with this requirement to ensure your child’s enrollment and attendance.

Form Specifications

Fact Name Fact Description
Purpose The Oregon 53 05A form certifies a child's immunization status for school or daycare attendance.
Governing Law Oregon law requires proof of immunization or a signed exemption before a child can attend school or daycare.
Immunization Records Parents must list immunizations in the order received, including dates for each dose.
Signature Requirement A parent, guardian, or qualified individual must sign the form to verify the accuracy of the immunization history.
Exemption Types Oregon allows both medical and nonmedical exemptions from immunizations.
Recommended Vaccines The form includes a section for recommended vaccines, which are not legally required but are advised for children.
Medical Exemptions For medical exemptions, a letter from a licensed physician is required, detailing the child's condition and contraindicated vaccines.
Nonmedical Exemption Documentation To obtain a nonmedical exemption, parents must submit a certificate from a healthcare practitioner or complete a vaccine education module.
Data Collection The information collected may be shared with the Oregon Health Authority or local public health departments upon request.
Form Updates Any updates to the child's immunization information require the form to be re-signed by the parent or guardian.