Connecticut students who have received their initial immunizations but still need others can attend school when their provider certifies that the remaining doses are in process. On this one-page DPH form, the provider certifies the student is their patient and that they will give the outstanding vaccines following the Commissioner's Schedule for In Process Required School Immunizations.
The student's primary care provider, licensed as a physician (MD or DO), PA or APRN, enters their name, license type, Connecticut license number, contact details, signature and date, plus the student, parent and school details.
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Healthcare Provider's Certification of In Process Required School Immunizations
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The form requires providers to follow the CDC catch-up schedule using the minimum spacing interval between doses and to complete the remaining required immunizations no later than 30 days after the minimal interval has passed. The certification commits the provider to that DPH schedule for the named student.
The student's physician (MD or DO), physician assistant or APRN. The signer checks their license type and enters a Connecticut license number, phone and email, then signs and dates. The certification also states that the student is the signer's patient.