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Blank Vaccine Form: What You Should Know

Agency Name: 2. “Virus antigen concentration (in units of Viral Shedding Capacity (VSC) divided by 2. This statement reflects that the student has been exposed to a particular infectious agent for a period of at least 24  hours. The statement also states that the individual is not immunosuppressive. This information is needed by the School when deciding whether to require proof of immunity for a child attending their program. Agency Name: 3. Viral Shedding Capacity Unit (VSC):. This measurement reflects the number of times an individual will shed infectious viral nuclei for each virus that was  immunized. For example, a vaccine that is good for the entire life of a 7-year-old child will result a value of 1. A vaccine that will protect from rabies for 24 hours, for example, has a VSC value of 2. The unit used to determine the unit value for a virus was chosen because it is an easy to interpret and measure unit. Since the disease that was  vaccinated against is a very rare disease the risk for the spread of this disease can be  difficult to estimate. Vaccine is considered protective if it confers 100% protection or greater.  Health care workers (e.g., pediatrician) might consider measuring the maximum  VSC value. This will result in a value of 1.00 and provides one point for each of the 4 immune  systems, 2 for each of the 4 immune cell types and 2 for each of the 4 viral  subtypes. If the maximum value is less than 1 the immunity is considered to be null or low. Agency Name: (Optional: Immunization History Form) Health Care Provider or School Official Name: Signature: Date:_______. If verified by school or child care staff the medical  immunization records must be signed by a physician or school employee. Agency Name: 4. Vaccination History form for students vaccinated in another state with the same or different immunization schedule. Agency Name: Additional Information (Required).

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