Purpose: The rule has been reviewed and redrafted to improve its clarity, note changes in reporting, and update Advisory Committee on Immunization Practice (ACIP) recommendations on childhood and adolescent immunization. In 2003, the State Board of Health determined that current language could be made more clear. Since the rule's original adoption in 1997, new technology makes it possible to consider a single reporting date and electronic filing for schools, preschools, and childcare centers. In addition, the ACIP has revised the childhood and adolescent immunization schedule yearly.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-100-166.

     Statutory Authority for Adoption: RCW 28A.210.140.

      Adopted under notice filed as WSR 05-04-113 on February 2, 2005.

     A final cost-benefit analysis is available by contacting Karen Arbogast, P.O. Box 47830, Olympia, WA 98504, phone (360) 236-3540, fax (360) 236-3590, e-mail Karen.Arbogst@doh.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: March 30, 2005.

Craig McLaughlin

Executive Director

State Board of Health

OTS-7632.7

AMENDATORY SECTION(Amending WSR 96-04-079, filed 2/7/96, effective 3/9/96)

WAC 246-100-166   Immunization of child care and school children against certain vaccine-preventable diseases.   (1) ((Definitions for purposes of this section:

     (a) "Certificate of immunization status (CIS) form" means a form provided by the department labeled DOH 348-013, including data entry spaces for immunization information including:

     (i) Name of child or student,

     (ii) Birth date,

     (iii) Gender,

     (iv) Type of vaccine,

     (v) Date of each dose of vaccine received specifying day, month, and year,

     (vi) Signature of parent, legal guardian, or adult in loco parentis, and

     (vii) Documented exemptions, if applicable and as specified in subsection (5) of this section.

     (b))) Purpose. Under the authority of RCW 43.20.050 and 28A.210.140, the state board of health is empowered to adopt rules to establish immunization requirements upon entry into school and child care. The following rule improves the public health of Washington by preventing vaccine-preventable disease outbreaks.

     (2) Definitions. The words and phrases in this section have the following meanings:

     (a) Certificate of immunization status (CIS) means:

     (i) A certificate of immunization status form approved by the department; or

     (ii) A CHILD profile immunization record; or

     (iii) Any other immunization form approved by the department.

     (b) "Chief administrator" means:

     (i) The person with the authority and responsibility for ((the immediate supervision of the)) supervising the immediate operation of a school((,)) or child care ((center,)); or

     (ii) A ((designee of the chief administrator assigned)) person designated in writing ((to carry out the requirements of RCW 28A.210.160 through)) by the statutory or corporate board of directors of the school district or school((,)); or

     (iii) In the absence of the above, a person or persons with the authority and responsibility for supervising the general ((supervision of the)) operation of the school district ((or school)).

     (c) "Child" means any person regardless of age admitted to ((any child care center, preschool, kindergarten, or grades one through twelve program of education in)):

     (i) Any public school district((,)); or

     (ii) Any private school or private institution subject to approval by the state board of education or described in RCW 28A.305.130 and 28A.195.010 through 28A.195.060((,)); or

     (iii) Any ((licensed)) child care ((facility which regularly provides care for a group of thirteen or more children for periods of less than twenty-four hours subject to licensure by the department of social and health services as described in chapter 74.15 RCW)) center.

     (d) (("Full immunization" means vaccinated in accordance with schedules and immunizing agents approved by the state board of health in WAC 246-100-166 against:

     (i) Diphtheria,

     (ii) Tetanus,

     (iii) Pertussis or whooping cough,

     (iv) Measles or rubeola,

     (v) Rubella,

     (vi) Mumps,

     (vii) Poliomyelitis,

     (viii) Haemophilus influenzae type b disease, and

     (ix) Hepatitis b, after September 1, 1997.

     (e))) "Child care center" means any licensed facility or center that regularly provides care of children for periods of less than twenty-four hours per day subject to licensure by the department of social and health services as described in chapter 74.15 RCW.

     (e) "Conditional status" is a type of immunization status where a child is not fully immunized under (g) of this subsection and is in the process of completing the required immunizations for his/her age.

     (f) "Exemption" is a type of immunization status where a child is not fully immunized under (g) of this subsection and meets school and child care documentation requirements under subsection (4)(b)(i) of this section.

     (g) "Full immunization" or "fully immunized" is an immunization status where a child has been vaccinated at ages and intervals consistent with the National Immunization Guidelines, with immunizing agents against:

     (A) Diphtheria;

     (B) Tetanus;

     (C) Pertussis (whooping cough);

     (D) Poliomyelitis;

     (E) Measles (rubeola);

     (F) Mumps;

     (G) Rubella;

     (H) Hepatitis B; and

     (I) Haemophilus influenzae type B disease.

     (h) "Immunizing agent((s))" means any vaccine or other ((biologic)) immunologic drug licensed and approved by the United States Food and Drug Administration (FDA), or meeting World Health Organization (WHO) requirements, for immunization of persons against((:

     (i) Diphtheria, tetanus, pertussis (DTP, DT, Td);

     (ii) Measles;

     (iii) Mumps;

     (iv) Poliomyelitis, types I, II, and III (TOPV, IPV);

     (v) Rubella;

     (vi) Haemophilus influenzae type b vaccine (Hib); and

     (vii) Hepatitis b.

     (f))) vaccine-preventable diseases.

     (i) "Local health officer" means the individual appointed under chapter 70.05 RCW as the health officer for the local health department, or appointed under chapter 70.08 RCW as the director of public health of a combined city-county or combined county health district.

     (j) "National Immunization Guidelines" means the schedule for the immunization described in the "Recommended Childhood and Adolescent Immunization Schedule: United States -- ((January 1995,)) 2005" approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

     (((g))) (k) "Parent" means ((a person who is)), for the purposes of signature requirements in this rule:

     (i) The mother, father, legal guardian, or any adult in loco parentis of a child seventeen years of age or younger; or

     (ii) A person eighteen years of age or older; or

     (iii) An emancipated minor.

     (((h) "Transfer student" means a student previously enrolled in grades kindergarten through twelve moving from one school district or system to another at any time during the school year, excluding students transferring within a district or system when the school transfers records within the district.

     (2) Full immunization schedule. Each child care center, preschool, and school shall establish and maintain requirements for full immunization of children attending child care and preschool through grade twelve.

     (3) For child care and preschool children, full immunization means a child received age-appropriate vaccines as enumerated in the National Immunization Guidelines as defined in subsection (1) of this section.

     (4) For a child entering kindergarten or first grade (school entry level), full immunization means a child received age-appropriate vaccines as enumerated in the National Immunization Guidelines as defined in subsection (1) of this section.

     For transfer students and those above kindergarten or first grade, full immunization means a child received age-appropriate vaccines consistent with the National Immunization Guidelines as defined in subsection (1) of this section (not required of persons eighteen years of age and older).

     (5) Conditions for child care, preschool, and school attendance when a child is not fully immunized:

     (a) When a child lacks full immunization, the child care center, preschool, or school shall require satisfactory progress toward full immunization (conditional status) as a condition of school attendance including:

     (i) Documented proof of start or continuance of child's schedule of immunization;

     (ii) Assurance the scheduled immunization is consistent with the national immunization guidelines defined in subsection (1) of this section;

     (iii) Notification of child's parent(s) of when the schedule must be completed; and

     (iv) Exclusion of child from attendance as described in subsection (9) of this section if child has not received required immunizations on schedule and if sufficient time has elapsed (one month from date due) for completion of next dose.

     (6) Schools, preschools, and child care centers shall require documented proof related to immunization including:

     (a) Completion of a certificate of immunization status (CIS) form by a parent as documented proof of:

     (i) Full immunization, or

     (ii) Initiation or continuation of a schedule (conditional status), or

     (iii) Exemption.

     (b) Information from a written personal immunization record, as the source of the immunization data entered on the CIS form (substitution of a personal immunization record for a CIS form is prohibited);

     (c) Acceptance of only the CIS form (no other state or local immunization forms) from new enrollees registering in kindergarten through grade twelve;

     (d) In addition to current CIS form, acceptance of previous CIS forms, or locally developed forms approved by the department indicating the month and year of each immunization as the official immunization status for children enrolled prior to September 1, 1979.

     (7) Schools, preschools, and child care centers shall accept medical exemptions and:

     (a) Require a signature of a licensed medical doctor (M.D.), doctor of osteopathy (D.O.), doctor of naturopathy (N.D.), physician assistant, or nurse practitioner practicing within the limits of the medical or nurse practice acts to certify medical reasons to defer one or more immunizations on the CIS form;

     (b) Admit children and keep on file a CIS form for children with:

     (i) Temporary exemption from immunization for medical reasons if the required immunizations are received upon expiration of the exemption, or

     (ii) Permanent exemptions.

     (c) Include a statement on the CIS form informing the parent that should an outbreak of vaccine preventable disease for which the child is exempted occur, the child may be excluded from school or child care for the duration of the outbreak by order of the local health department as described in subsection (9) of this section; and

     (d) Keep on file a list of children so exempted and transmit the list to the local health department if requested.

     (8) Schools, preschools, and child care centers shall:

     (a) Allow a parent to exempt his/her child from the required immunizations for religious, philosophical, or personal objections when the CIS form indicates:

     (i) Type or exemption, and

     (ii) Signature of parent.

     (b) Keep on file a CIS form for each child so enrolled;

     (c) Include a statement on the CIS form informing the parent that should an outbreak of vaccine preventable disease for which the child is exempted occur, the child may be excluded from school for the duration of the outbreak by order of the local health department as described in subsection (9) of this section; and

     (d) Keep on file a list of children so exempted and transmit the list to the local health department if requested.

     (9) Schools, preschools, and child care centers shall exclude children from school as follows:

     (a) Exclude any child from school for failure to provide a completed CIS form as defined in subsection (1) of this section before or on the child's first day of attendance consistent with procedures required by the state board of education, Title 180 WAC;

     (b) Exclude from attendance any child in a child care center for failure to provide a completed CIS form as defined in subsection (1) of this section before or on the child's first day of attendance;

     (c) The chief administrator shall retain records on excluded children for at least three years including:

     (i) Name,

     (ii) Address, and

     (iii) Date of exclusion.

     (d) A health officer may exclude children from school, preschool, and child care attendance in the event of a child's exposure to a disease according to chapter 246-110 WAC, including children presenting proof of:

     (i) Initiation of a schedule of immunization,

     (ii) Medical exemption,

     (iii) Religious exemption,

     (iv) Philosophical exemption, or

     (v) Personal exemption.

     (10) Schools, preschools, and child care centers shall maintain records and require:

     (a) A completed CIS form retained in the files for every child enrolled;

     (b) Return of original CIS form or a legible copy to the parent in the event of the child's withdrawal or transfer from school (withholding a record for any reason, including nonpayment of school, preschool, or child care fees is prohibited);

     (c) Access to immunization records by agents of the state or local health department for each child enrolled.

     (11) Persons or organizations administering immunizations, either public or private, shall:

     (a) Furnish each person immunized, or his or her parent, with a written record of immunization containing information required by the state board of health; and

     (b) Provide immunizations and records in accordance with chapter 246-100 WAC.

     (12) Chief administrators of schools, preschools, and child care centers shall forward a written annual report to the department and local health department on the immunization status of children as follows:

     (a) For schools: By November 1 of each year on forms provided by the department (except in the event of a late school opening when the report is due thirty days after the first day of school);

     (b) For preschools and child care centers: By February 1 of each year on forms provided by the department.)) (l) "School" means a facility, site, or campus for programs of education as defined in RCW 28A.210.070 to include preschool and kindergarten through grade twelve.

     (3) Documentation of immunization status required by schools and child care center.

     (a) Schools and child care centers shall require documented proof of immunization status in the form of a CIS.

     (b) The CIS form must include:

     (i) Name of child or student;

     (ii) Birth date;

     (iii) Type of vaccine(s) administered;

     (iv) Month, day, and year of each dose of vaccine received;

     (v) Documentation of immunization status to indicate:

     (A) Full immunization under subsection (2)(g) of this section; or

     (B) Conditional status under subsection (2)(e) of this section; or

     (C) Exemption under subsection (2)(f) of this section;

     (vi) Notice to parents that if an outbreak of vaccine-preventable disease for which the child is exempted occurs, the child may be excluded from school or child care for the duration of the outbreak;

     (vii) Parent signature.

     (4) Duty of schools and child care centers.

     (a) Schools and child care centers shall require a CIS form, signed by parents, for new enrollees registering for admission into kindergarten through grade twelve or child care as a requirement of admission.

     (b) Full immunization is required upon admission unless:

     (i) Parent(s) sign and submit a CIS form indicating a medical exemption.

     (A) A permanent medical exemption is allowed when a signature of a licensed medical doctor (M.D.), a doctor of osteopathy (O.D.), doctor of naturopathy (N.D.), physician assistant (P.A.), or nurse practitioner (A.R.N.P.), acting within the scope of practice, certifies medical reasons to defer or forego one or more immunizations required for full immunization under subsection (2)(g) of this section.

     (B) If immunizations are deferred on a temporary basis, the student must receive the required immunizations upon expiration of the exemption.

     (ii) Parent(s) sign and submit a CIS form indicating a religious or philosophical, or personal exemption.

     (iii) Parent(s) sign and submit a CIS form indicating conditional status if there is evidence of satisfactory progress toward full immunization, including:

     (A) Documentation of start or continuance towards full immunization status;

     (B) Documentation that immunizations received are consistent with the National Immunization Guidelines defined in subsection (2)(j) of this section; and

     (C) Documentation of when the next immunization is due.

     (c) Schools and child care centers maintenance of child immunization records:

     (i) Schools and child care centers shall keep a department approved CIS for each enrolled child.

     (ii) Schools and child care centers shall keep a list of children with medical, religious, philosophical, or personal exemptions.

     (iii) The chief administrator shall retain records for at least three years on a child who is excluded from school under this section. The record must include the child's name, address, and date of exclusion.

     (d) Schools and child care centers shall transmit the list of children with medical, religious, philosophical, or personal exemptions to the local health department upon request.

     (e) A school or child care center shall return the department approved CIS or a legible copy to the parent if the child is withdrawn from school or child care or transferred from the school.

     (f) A school or child care center may not withhold a child's department approved CIS for any reasons, including nonpayment of school child care fees.

     (g) A school or child care center shall provide access to immunization records to agents of the state or local health department of each child enrolled.

     (h) The chief administrator of a school or child care center shall submit a school immunization status report under chapter 28A.210 RCW either electronically on the internet or on the school immunization status report provided by the department. The report must be:

     (i) Submitted to the department by November 1 of each year;

     (ii) If a school opens after October 1, the report is due thirty days from the first day of school.

     (5) Persons or organizations administering immunizations, either public or private shall:

     (a) Furnish each person immunized, or his or her parent, with a written record of immunization containing information required by the state board of health; and

     (b) Provide immunizations and records in accordance with chapter 246-100 WAC.

     (6) A school or child care center shall exclude a child if one or more of the following applies:

     (a) Parent(s) fail to provide a completed CIS form on or before the child's first day of attendance. Schools must use procedures consistent with Title 180 WAC.

     (b) A child admitted under conditional status has not received the required immunization(s) within one month from the date due for completion of the next dose.

     (c) A child has been admitted under a medical exemption and the particular vaccine for which the exemption was granted is no longer contraindicated and the child has not received the immunization within one month from the due date for completion of the next dose.

     (7) A local health officer may exclude a child from school or child care under chapter 246-110 WAC during an outbreak of a vaccine-preventable disease if the child has not been fully immunized against that disease due to:

     (a) Medical exemption;

     (b) Conditional status;

     (c) Religious exemption;

     (d) Philosophical exemption; or

     (e) Personal exemption.

[Statutory Authority: RCW 28A.210.140. 96-04-079, § 246-100-166, filed 2/7/96, effective 3/9/96. Statutory Authority: RCW 28A.210.140 and 43.20.050. 91-15-066 (Order 182B), § 246-100-166, filed 7/22/91, effective 8/22/91. Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as § 246-100-166, filed 12/27/90, effective 1/31/91; 88-07-063 (Order 308), § 248-100-166, filed 3/16/88.]

© Washington State Code Reviser's Office