12VAC5-110 Regulations for the Immunization of School Children

REGULATIONS

Vol. 25 Iss. 20 - June 08, 2009

TITLE 12. HEALTH

STATE BOARD OF HEALTH

Chapter 110

Proposed Regulation

Title of Regulation: 12VAC5-110. Regulations for the Immunization of School Children (amending 12VAC5-110-10, 12VAC5-110-20, 12VAC5-110-30, 12VAC5-110-70, 12VAC5-110-80, 12VAC5-110-90, 12VAC5-110-100, 12VAC5-110-130).

Statutory Authority: §§ 22.1-271.2, 32.1-12, and 32.1-46 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comments: Public comments may be submitted until August 7, 2009.

Agency Contact: James Farrell, Director, Division of Immunization, Department of Health, 109 Governor Street, Richmond, VA 23219, telephone [phone], or email [e-mail].

Basis: Sections 22.1-271.2 and 32.1-46 of the Code of Virginia authorize the State Board of Health to promulgate regulations relating to immunization requirements for school children.

Purpose: Regulations are necessary to ensure children are protected to the extent possible from vaccine-preventable diseases and to indirectly protect the health of Virginians. Legislation enacted by the 2006 Virginia General Assembly requires the regulations to be updated to reflect current immunization recommendations and also added two new required vaccines. Legislation enacted by the 2007 Virginia General Assembly added an additional new vaccine requirement. The regulations must be amended to bring them into conformance with the new legislation as well as with current immunization recommendations.

Substance: Amendments to the current regulations will (i) update and clarify definitions; (ii) update childhood immunizations required for attendance at Virginia schools and day cares to include additional required vaccines and reflect current recommended immunization practices; (iii) add requirements for demonstrating existing immunity to varicella; and (iv) update responsibilities of admitting officials.

Issues: The proposed regulations will ensure that children are protected to the extent possible from vaccine-preventable diseases and will indirectly protect the health of all citizens of Virginia. Disadvantages may include increased costs associated with providing additional required vaccines. Additional time may be needed for parents to obtain and providers to document required vaccines.

The Department of Planning and Budget Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The State Board of Health (Board) proposes to amend its regulations governing the immunization of school children to incorporate immunization requirements enacted by the legislature in 2006 and 2007 and to reflect changes in the current immunization schedule recommended by the American Academy of Pediatrics and the American Academy of Family Physicians (this is also required by statute). The Board also proposes to add registered nurses to the list of entities that can administer immunizations and can provide certification that required vaccines would be detrimental to a child’s health.

Result of Analysis. There is insufficient information to accurately gauge whether benefits will outweigh costs for this proposed regulatory action. Benefits and costs are discussed below.

Estimated Economic Impact. Currently, parents must make sure that their children have received a specified number of immunizations for specified diseases before they are enrolled in school (and continue receiving specified immunizations as a condition for staying enrolled). Alternately, parents may present a Certificate of Religious Exemption (CRE), certification from a physician or local health department that the required vaccines would be detrimental to their child’s health or, for rubeola and rubella, proof that the child already has antibodies and would not, therefore need to be vaccinated.

The current regulatory vaccination schedule requires:

• Three doses of Diphtheria and Tetanus toxiods and Pertussis vaccine (DPT) before the child is seven years old; One of these doses must be administered after the child is four years old,

• A minimum of three doses of the polio vaccine, one of which must be administered after a child is four years old,

• Two doses of live Rubeola (measles) vaccine, one administered at age 12 months or older and one administered prior to entering kindergarten (this requirement is clarified in the proposed regulations and will have the second dose administered between the ages of four and six),

• A minimum of one dose of Rubella (German measles) vaccine administered at age 12 months or older,

• A minimum of one dose of mumps vaccine administered at 12 months of age or older,

• A maximum of four doses of Haemophilus Influenza type b (Hib) vaccine on an approved schedule that is “appropriate to the age of child and the age at which the immunization series was initiated” and

• A minimum of three doses of the Hepatitis B vaccine.

According to current regulatory text, a physician or his designee or a local Departments of Health can attest to the administration of immunizations (or attest that a child would be harmed by same).

The Board proposes to update this regulatory vaccination schedule to reflect changes in statutory requirements and changes in the current immunization schedule recommended by the American Academy of Pediatrics and the American Academy of Family Physicians. The Board proposes to list the three component parts of the DPT vaccine separately and add the requirement that a booster of each must be given prior to a child’s enrollment in sixth grade, provided that at least five years had passed since the child’s last dose of each. Even though these components will be listed separately in these regulations, they are normally combined into one shot for the purposes of childhood immunization. The proposed regulations include a required second dose of the mumps vaccine, to be administered between the ages of four and six, and an addition to the requirements for the Hepatitis B vaccine that allows children between the ages of 11 and 15 to only take two (rather than three) doses of this vaccine so long as they are taking the newly approved RECOMBIVAX HB produced by Merck.

The proposed regulations also include recently (in the last two years) passed legislative requirements that children born on or after January 1, 1997 receive two doses of the Varicella (chickenpox) vaccine, one dose on or after the age of 12 months and one dose between the ages of four and six, that all children under the age of 24 months receive a maximum of four doses of Pneumococcal Conjugate Vaccine (PCV) to protect against pneumonia and that girls must have three doses of the Human Papillomavirus (HPV), the first of which must be administered before admittance to sixth grade. Because HPV is not a disease that is communicable in a school setting and because requiring this vaccine is not without controversy, parents (guardians) may choose not to allow the HPV vaccine to be give to their daughters (charges). These parents (guardians) must review materials describing the link between certain HPV strains and cervical cancer prior to deciding whether to allow the vaccine to be given but do not have to sign a waiver.

The proposed regulations also includes chickenpox among the diseases for which a child does not need the vaccine if he already has antibodies and clarifies by explicitly listing registered nurses as individuals empowered to give vaccines or to certify, when necessary, that vaccines cannot be given because they would be harmful to a child.

Requiring a booster of each of the components of the DPT vaccine before a child enters sixth grade currently entails either an extra visit to the child’s doctor (either completely paid for by the parent or with the cost split between the parent and their insurance company) or a visit to a local Department of Health where the vaccine will be given at no fee to the parent but where the parent may spend many hours waiting for the shot to be given. Parents who choose to allow their daughters to receive the HPV vaccine would likely choose to have this vaccine given at the same time as the DPT booster and, so, could lower the per shot cost (of time or money or both). Parents who do not choose to allow their daughters to receive the HPV virus will incur the cost of time spent reading Board approved materials about the link between HPV and cervical cancer.

Parents who will be immunizing infants and toddlers with the PCV vaccine, and parents whose children will be required to be vaccinated against chickenpox, will likely be able to have these vaccines administered with other required vaccines at normal well child visits. Any costs for parents for the PCV and chickenpox vaccines will likely be limited to any out of pocket costs for the vaccine doses themselves (this would likely only be an issue for parents paying all costs themselves since most insurance plans cover vaccines in the copay cost of well child visits).

The requirement for an additional dose of mumps vaccine and the allowance for a two dose course of Hepatitis B vaccine will likely not raise the total cost (in time or money) of immunization for parents who are having their children immunized on the recommended schedule because the recommended schedule already includes two doses of the combined measles, mumps and rubella (MMR) vaccine and because parents are unlikely to choose the two dose Hepatitis B vaccine unless they receive some benefit over the normal three dose course.

The Virginia Department of Health (VDH) reports that the state will incur extra costs for vaccines paid for by the state, and administered through local Departments of Health, and that local Departments of Health will likely lose revenue (costs for office visit and administration of vaccine) that they have received from parents paying for the optional second dose of chickenpox vaccine. The state has budgeted $1.4 million per year to cover the cost of the HPV vaccine and $280,110 per year to cover the (local Department of Health) cost of requiring the DPT booster before sixth grade. Local Departments of Health currently charge approximately $30 per child for administering a second chickenpox immunization; the state already pays for the actual vaccine doses.

To the extent that the new immunization schedule lowers the incidence of the diseases covered by the required vaccines, the public will benefit from fewer costs for illness (misery, permanent injury or death for the sick children, costs for medication to ameliorate symptoms and lost wages for parents) and, for diseases that are easily spread in a school setting, greater herd immunity. Any extra benefit from the changes to required immunizations have to be weighed against the not insignificant increases in costs to the state, to parents and to insurance companies.

Businesses and Entities Affected. VDH reports that these proposed regulations will affect parents and their children, all public and private health care providers who administer covered vaccines as well as school staff who must verify that children are in compliance with the required vaccine schedule. These proposed regulations will also likely affect insurance companies that cover required vaccinations.

Localities Particularly Affected. All local Departments of Health will likely lose revenue (costs for office visit and administration of vaccine) that they have received from parents paying for the optional second dose of chickenpox vaccine. Local Departments of Health currently charge approximately $30 per child for administering a second chickenpox immunization; the state pays for the actual vaccine doses.

Projected Impact on Employment. This regulatory action will likely have no impact on employment in the Commonwealth.

Effects on the Use and Value of Private Property. This regulatory action will likely have no effect on the use or value of private property in the Commonwealth.

Small Businesses: Costs and Other Effects. Small businesses in the Commonwealth are unlikely to incur any costs on account of this regulatory action.

Small Businesses: Alternative Method that Minimizes Adverse Impact. Small businesses in the Commonwealth are unlikely to incur any costs on account of this regulatory action.

Real Estate Development Costs. This regulatory action will likely have no effect on real estate development costs in the Commonwealth.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 36 (06). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB’s best estimate of these economic impacts.

Agency's Response to the Department of Planning and Budget Economic Impact Analysis: Virginia Department of Health concurs substantially with the economic impact analysis prepared by the Department of Planning and Budget on this proposed regulation.

Summary:

The proposed amendments (i) incorporate immunization requirements enacted by the legislature in 2006 and 2007, (ii) reflect changes in the current immunization schedule recommended by the American Academy of Pediatrics and the American Academy of Family Physicians, and (iii) add registered nurses to the list of entities that can administer immunizations and can provide certification that required vaccines would be detrimental to a child’s health.

Part I
Definitions

12VAC5-110-10. Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

"Adequate immunization" means the immunization requirements prescribed under 12VAC5-110-70.

"Admit" or "admission" means the official enrollment or reenrollment for attendance at any grade level, whether full-time or part-time, of any student by any school.

"Admitting official" means the school principal or his designated representative if a public school; if a nonpublic school or child care center, the principal, headmaster or director of the school or center.

"Board" means the State Board of Health.

"Commissioner" means the State Health Commissioner.

"Compliance" means the completion of the immunization requirements prescribed under 12VAC5-110-70.

"Conditional enrollment" means the enrollment of a student for a period of 90 days contingent upon the student having received at least one dose of each of the required vaccines and the student possessing a plan, from a physician or local health department, for completing his immunization requirements within the ensuing 90 calendar days. If the student requires more than two doses of Hepatitis B vaccine, the conditional enrollment period shall be 180 calendar days.

"Documentary proof" means an appropriately completed copy of Form MCH 213B and the temporary certification form for Haemophilus influenzae type b disease where applicable, Form MCH 213C or a computer generated facsimile of Form 213C 213F signed by a physician or his designee, registered nurse, or an official of a local health department. The MCH 213C SUPPLEMENT A copy of the immunization record signed or stamped by a physician or his designee, registered nurse, or an official of a local health department indicating the dates of administration including month, day, and year of the required vaccines, shall be acceptable in lieu of recording these dates on Form MCH 213C 213F, as long as the supplement record is attached to Form MCH 213C 213F and the remainder of Form MCH 213C 213F has been appropriately completed. For a new student transferring from an out-of-state school, any immunization record, which contains the exact date (month/day/year) of administration of each of the required doses of vaccines when indicated, is signed by a physician of his designee or registered nurse, and complies fully with the requirements prescribed under 12VAC5-110-70 shall be acceptable.

"Immunization" means the administration of a product licensed by the FDA to confer protection against one or more specific pathogens.

"Immunization schedule" means the schedule developed and published by the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

"Physician" means any person licensed to practice medicine in any of the 50 states or the District of Columbia.

"School" means:

1. Any public school from kindergarten through grade 12 operated under the authority of any locality within this Commonwealth;

2. Any private or parochial religious school that offers instruction at any level or grade from kindergarten through grade 12;

3. Any private or parochial religious nursery school or preschool, or any private or parochial religious child care center required to be licensed by this Commonwealth; and

4. Any preschool handicapped classes or Head Start classes operated by the school divisions within this Commonwealth.

"Student" means any person less than 20 years of age who seeks admission to any Virginia school, or for whom admission to any Virginia school is sought by a parent or guardian who seeks admission to a school, or for whom admission to a school is sought by a parent or guardian, and who will not have attained the age of 20 years by the start of the school term for which admission is sought.

"Twelve months of age" means the 365th day following the date of birth. For the purpose of evaluating records, vaccines administered up to four days prior to the first birthday (361 days following the date of birth) will be considered valid.

Part II
General Information

12VAC5-110-20. Purpose.

This chapter is designed to ensure that all students attending any public, private or parochial school and all attendees of licensed child care centers in the Commonwealth, are adequately immunized and protected against diphtheria, pertussis, tetanus, poliomyelitis, rubeola, rubella, mumps, haemophilus influenzae type b, and hepatitis B, varicella, pneumococcal, and human papillomavirus disease as appropriate for the age of the student.

12VAC5-110-30. Administration.

A. The Board of Health has the responsibility for promulgating regulations pertaining to the implementation of the school immunization law and standards of immunization by which a child attending a any school or child care center may be judged to be adequately immunized.

B. The State Health Commissioner is the executive officer for the State Board of Health with the authority of the board when it is not in session, subject to the rules and regulations of the board.

C. The local health director is responsible for providing assistance in implementing this chapter to the school divisions in his jurisdiction and for providing immunizations to children determined not to be adequately immunized, who present themselves to the local health department for immunization.

D. The school principals of public schools and the principals, headmasters and directors of nonpublic schools and child care centers shall require each student attending their institutions to provide documentary proof of immunization against the diseases listed in 12VAC5-110-70.

Part III
Immunization Requirements

12VAC5-110-70. Immunization requirements.

Every new student and every child attending a licensed child care center enrolling in a school shall provide documentary proof of adequate immunization with the prescribed number of doses of each of the vaccines and toxoids listed in the following subdivisions, as appropriate for his age according to the immunization schedule. Spacing, minimum ages, and minimum intervals shall be in accordance with the immunization schedule. A copy of every student's immunization record shall be on file in his school record.

1. Diphtheria and Tetanus Toxoids and Pertussis Vaccine (DTP). For students less than seven years of age, a minimum of three doses of DTP,with one dose administered after the student's fourth birthday. If any of these three doses must be administered on or after the seventh birthday, Td (adult tetanus toxoid full dose and diphtheria toxoid reduced dose) should be used instead of DTP.

1. Diphtheria Toxoid. A minimum of four or more properly spaced doses of diphtheria toxoid. One dose shall be administered on or after the fourth birthday. A booster dose shall be administered prior to entering the sixth grade if at least five years have passed since the last dose of diphtheria toxoid.

2. Tetanus Toxoid. A minimum of four or more properly spaced doses of tetanus toxoid. One dose shall be administered on or after the fourth birthday. A booster dose shall be administered prior to entering the sixth grade if at least five years have passed since the last dose of tetanus toxoid.

3. Acellular Pertussis Vaccine. A minimum of four or more properly spaced doses of acellular pertussis vaccine. One dose shall be administered on or after the fourth birthday. A booster dose shall be administered prior to entering the sixth grade if at least five years have passed since the last dose of pertussis vaccine.

2. 4. Poliomyelitis Vaccine. A minimum of three doses of all trivalent oral poliomyelitis vaccine (OPV) or all inactivated polio vaccine (IPV), with one dose administered after the fourth birthday or three doses of enhanced-potency inactivated poliomyelitis vaccine (IPV), with one dose administered after the fourth birthday when OPV is contraindicated.

3. 5. Measles (Rubeola) Vaccine. For students enrolling in kindergarten or first grade on and after July 1, 1991, one One dose of live measles vaccine administered at age 12 months or older, and a second dose administered at four to six years of age or prior to entering kindergarten or first grade, whichever occurs first. The two doses must be administered at least one month apart. Students entering sixth grade on and after July 1, 1992, shall also have received two doses of live measles vaccine, with the first dose administered at age 12 months or older and the second dose at least one month after the first dose. All other students shall have received at least one dose of live measles vaccine. Any measles immunization received after 1968 should be considered to have been administered using a live virus vaccine.

4. German Measles (Rubella) 6. Rubella Vaccine. A minimum of one dose of rubella virus vaccine administered at age 12 months or older.

5. 7. Mumps Vaccine. A minimum of one One dose of mumps virus vaccine administered at age 12 months or older and a second dose administered at four to six years of age or prior to entering kindergarten. The requirement for mumps vaccine shall not apply to any child admitted for the first time to any grade level, kindergarten through grade 12 of a school prior to August 1, 1981.

6. 8. Haemophilus Influenzae Type b (Hib) Vaccine. A complete series of Hib vaccine i.e., up to a maximum of four doses of vaccine as appropriate for the age of the child and the age at which the immunization series was initiated. The number of doses administered shall be in accordance with current immunization schedule recommendations of either the American Academy of Pediatrics or those of the U.S. Public Health Service. Attestation by the physician or his designee, registered nurse, or an official of a local health department on the temporary form documenting immunizations against Hib, that portion of Form MCH 213C 213F pertaining to Hib vaccine, a computer generated facsimile of MCH 213C, or on the MCH 213C Supplement as defined in 12VAC5-110-10 under "documentary proof" shall mean that the child has satisfied the requirements of this section. This section shall not apply to children older than 30 60 months of age or for admission to any grade level, kindergarten through grade 12.

The dosage schedule for Hib vaccine varies with the manufacturer. The number of doses of vaccine required is also governed by the age at which immunization is initiated. Hence the reason why the requirements for Hib vaccine are prescribed in a manner different from those for the other vaccines.

7. 9. Hepatitis B Vaccine. A minimum of three doses of hepatitis B vaccine for all children born on or after January 1, 1994. The FDA has approved a two-dose schedule only for adolescents 11 through 15 years of age and only when the Merck brand (RECOMBIVAX HB) Adult Formulation Hepatitis B vaccine is used. The two RECOMBIVAX HB adult doses must be separated by a minimum of four months. The two dose schedule using the adult formulation must be clearly documented in the Hepatitis B section on Form MCH 213F.

10. Varicella (Chickenpox) Vaccine. All susceptible children born on and after January 1, 1997, shall be required to have one dose of chickenpox vaccine on or after 12 months of age and a second dose administered at four to six years of age or prior to entering kindergarten.

11. Pneumococcal Conjugate Vaccine (PCV). A complete series of PCV, i.e., up to a maximum of four doses of vaccine as appropriate for the age of the child and the age at which the immunization series was initiated. The number of doses administered shall be in accordance with current immunization schedule recommendations. Attestation by the physician or his designee, registered nurse, or an official of a local health department on that portion of Form MCH 213F pertaining to PCV vaccine shall mean that the child has satisfied the requirements of this section. This section shall not apply to children older than 24 months of age.

12. Human Papillomavirus (HPV) Vaccine. Three doses of properly spaced HPV vaccine for females, effective October 1, 2008. The first dose shall be administered before the child enters the sixth grade.

12VAC5-110-80. Exemptions from immunization requirements.

A. Religious and medical exemptions. No certificate of immunization shall be required of any student for admission to school if:

1. The student or his parent or guardian submits a Certificate of Religious Exemption (Form CRE 1), to the admitting official of the school to which the student is seeking admission. Form CRE 1 is an affidavit stating that the administration of immunizing agents conflicts with the student's religious tenets or practices. For a student enrolled before July 1, 1983, any document present in the student's permanent school record claiming religious exemption shall be acceptable, The form is available on the Division of Immunization website at http://www.vdh.virginia.gov//Epidemiology/Immunization/requirements.htm; or

2. The school has written certification on any either of the documents specified under "documentary proof" in 12VAC5-110-10 from a physician, registered nurse, or a local health department that one or more of the required immunizations may be detrimental to the student's health. Such certification of medical exemption shall specify the nature and probable duration of the medical condition or circumstance that contraindicates immunization. For a student enrolled before July 1, 1983, any document attesting to the fact that one or more of the required immunizations may be detrimental to the student's health shall be acceptable.

3. Upon the identification of an outbreak, potential epidemic, or epidemic of a vaccine-preventable disease in a public or private school, the commissioner has the authority to require the exclusion from such school of all children who are not immunized against that disease.

B. Demonstration of existing immunity. The demonstration in a student of antibodies against either rubeola or, rubella, or varicella in sufficient quantity to ensure protection of that student against that disease, shall render that student exempt from the immunization requirements contained in 12VAC5-110-70 for the disease in question. Such protection should be demonstrated by means of a serological testing method appropriate for measuring protective antibodies against rubeola or, rubella, or varicella respectively. Reliable history of chickenpox disease diagnosed or verified by a health care provider shall render students exempt from varicella requirements.

C. HPV vaccine. Because the human papillomavirus is not communicable in a school setting, a parent or guardian, at the parent's or guardian's sole discretion, may elect for the parent's or guardian's child not to receive the HPV vaccine, after having reviewed materials describing the link between the human papillomavirus and cervical cancer approved for such use by the board.

Part IV
Procedures and Responsibilities

12VAC5-110-90. Responsibilities of admitting officials.

A. Procedures for determining the immunization status of students. Each admitting official or his designee shall review, before the first day of each school year, the school medical record of every new student seeking admission to his school, and that of every student enrolling in grade six for compliance with the measles vaccine requirements prescribed in subdivisions 1, 2, and 3 of 12VAC5-110-70 3. Such review shall determine into which one of the following categories each student falls:

1. Students whose immunizations are adequately documented and complete in conformance with 12VAC5-110-70. Students with documentation of existing immunity to measles, rubella, or varicella as defined in 12VAC5-110-80 B shall be considered to be adequately immunized for such disease.

2. Students who are exempt from the immunization requirements of 12VAC5-110-70 because of medical contraindications or religious beliefs provided for by 12VAC5-110-80.

3. Students whose immunizations are inadequate according to the requirements of 12VAC5-110-70.

4. Students without any documentation of having been adequately immunized.

B. Notification of deficiencies. Upon identification of the students described in subdivisions A 3 and 4 of 12VAC5-110-90 A this section, the admitting official shall notify the student or his parent or guardian of the student:

1. That there is no, or insufficient, documentary proof of adequate immunization in the student's school records.

2. That the student cannot be admitted to school unless he has documentary proof that he is exempted from immunization requirements pursuant to 12VAC5-110-70.

3. That the student may be immunized and receive certification by a licensed physician, registered nurse, or an official of a local health department.

4. How to contact the local health department to receive the necessary immunizations.

C. Conditional enrollment. Any student whose immunizations are incomplete may be admitted conditionally if that student provides documentary proof at the time of enrollment of having received at least one dose of the required immunizations accompanied by a schedule for completion of the required doses within 90 calendar days, during which time that student shall complete the immunizations required under 12VAC5-110-70. The following table contains a suggested plan for ensuring the completion of these requirements within the 90 day conditional enrollment period. If the student requires more than two doses of Hepatitis B vaccine, the conditional enrollment period shall be 180 calendar days. If a student is a homeless child or youth and does not have documentary proof of necessary immunizations or has incomplete immunizations and is not exempted from immunization as described in 12VAC5-110-80, the school administrator shall immediately admit such student and shall immediately refer the student to the local school division liaison, who shall assist in obtaining the documentary proof of, or completing, immunizations. The admitting official should examine the records of any conditionally enrolled student at regular intervals to ensure that such a student remains on schedule with his plan of completion.

A SUGGESTED PLAN FOR ENSURING COMPLIANCE
TIME	ACTION STEP
Day 0	Conditional enrollment period starts. If student has not received first dose(s) of required vaccines, exclude student.
Day 1 to Day 42	Student should have received second dose(s) of required vaccines.
Day 43 to Day 88	Student should have received third dose(s) of required vaccines.
Day 89 and Day 90	Confirm that immunizations are completed; exclude children not in compliance.

D. Exclusion. The admitting official shall, at the end of the conditional enrollment period, exclude any student who is not in compliance with the immunization requirements under 12VAC5-110-70 and who has not been granted an exemption under 12VAC5-110-80 until that student provides documentary proof that his immunization schedule has been completed, unless documentary proof, that a medical contraindication developed during the conditional enrollment period, is submitted.

E. Transfer of records. The admitting official of every school shall be responsible for sending a student's immunization records or a copy thereof, along with his permanent academic or scholastic records, to the admitting official of the school to which a student is transferring within 30 days of his transfer to the new school.

F. Report of student immunization status. Each admitting official shall, within 30 days of the beginning of each school year or entrance of a student, or by October 15 of each school year, file with the State Health Department through the health department for his locality, a report summarizing the immunization status of the students in his school. This report shall be filed using the web-enabled reporting system or on Form SIS 1, the Student Immunization Status Report, and shall contain the number of students admitted to that school with documentary proof of immunization, the number of students who have been admitted with a medical or religious exemption and the number of students who have been conditionally admitted. The report for students entering the sixth grade shall include the number with a booster dose of tetanus, diphtheria, or pertussis containing vaccine within the last five years.

G. Each admitting official shall ensure that the parent or guardian of a female to be enrolled in the sixth grade receives educational materials describing the link between the human papillomavirus and cervical cancer. Materials shall be approved by the board and provided to the parent or guardian prior to the child's enrollment in the sixth grade.

12VAC5-110-100. Responsibilities of physicians and local health departments.

A. Documentary proof for students immunized in Virginia. Every physician, registered nurse, and local health department providing immunizations to a child shall provide documentary proof, as defined in 12VAC5-110-10, to the child or his parent or guardian of all immunizations administered.

B. Documentary proof for out-of-state students. For a student transferring from an out-of-state school to a Virginia school, the admitting official may accept as documentary proof any immunization record for that student which that is signed by a physician or nurse and that contains the exact date (month/day/year) of administration of each of the required doses of vaccines when indicated and which that complies fully with the requirements prescribed under 12VAC5-110-70. Any immunization record which that does not contain the signature of a physician or a nurse and does not contain the month/day/year of administration of each of the required vaccine doses shall not be accepted by the admitting official as documentary proof of adequate immunization with the exception of immunization against Hib. Such a student's record shall be evaluated by an official of the local health department who shall determine if that student is adequately immunized in accordance with the provisions of 12VAC5-110-70. Should the local health department determine that such a student is not adequately immunized, that student shall be referred to his private physician or local health department for any required immunizations.

12VAC5-110-130. Responsibility of parent to have a child immunized.

In accordance with § 32.1-46 of the Code of Virginia, "the parent, guardian or person standing in loco parentis of each child within this Commonwealth shall cause such child to be ensure such child is immunized by vaccine against diphtheria, tetanus, whooping cough and poliomyelitis and hepatitis B before such child attains the age of one year, against Haemophilus influenzae type b before he attains the age of 30 months, and against measles (rubeola), German measles (rubella) and mumps before such child attains the age of two years. All children shall also be required to receive a second dose of measles (rubeola) vaccine in accordance with the regulations of the board. The board's regulations shall require that all children receive a second dose of measles (rubeola) vaccine prior to first entering kindergarten or first grade and that all children who have not yet received a second dose of measles (rubeola) vaccine receive such second dose prior to entering the sixth grade." in accordance with the immunization schedule.

The parent or guardian of a child who is home instructed shall ensure such child is immunized in accordance with § 22.1-271.4 of the Code of Virginia.

Penalties for noncompliance shall be in accordance with § 32.1-27 of the Code of Virginia.

NOTICE: The forms used in administering the above regulation are not being published; however, the name of each form is listed below. The forms are available for public inspection by contacting the agency contact for this regulation, or at the office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia.

FORMS (12VAC5-110)

Certificate of Religious Exemption, CRE 1 (Eff. CRE-1, Rev. 00/92 (eff. 7/83).

School Entrance Physical Examination and Immunization Certification, MCH-213C (Rev. 10/91) MCH 213F (rev. 04/07).

DOCUMENTS INCORPORATED BY REFERENCE (12VAC5-110)

2009 Recommended Immunization Schedule for Persons Aged 0 through 6 Years, U.S. Department of Health and Human Services.

2009 Recommended Immunization Schedule for Persons Aged 7 through 18 Years, U.S. Department of Health and Human Services.

VA.R. Doc. No. R08-1339; Filed May 15, 2009, 1:05 p.m.