Wisconsin schools collect this record to measure compliance with the student immunization law (Wis. Stat. 252.04). Parents list vaccine dates and return it within 30 school days of admission. Clinicians sign in two places: to attest a reliable history of varicella disease or titer-proven immunity, and on the health waiver line when a student should not receive certain vaccines for health reasons.
The parent, guardian, legal custodian or adult student completes most of the form and signs Step 5. A physician, physician assistant or advanced practice nurse prescriber signs the varicella and titer attestation, and a physician signs the health waiver.
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Student Immunization Record
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A physician, physician assistant or advanced practice nurse prescriber signs the attestation that the student has a reliable history of varicella disease, and the same signature line covers titers showing immunity to varicella, measles, mumps, rubella or hepatitis B, with lab reports attached.
State law requires public and private school students to present written evidence of immunization within 30 school days of admission. The parent returns this form to the school by then, either showing all requirements are met or checking the in-progress or waiver option.