Mississippi Certificate of Immunization Compliance Form No. 121
The Mississippi Certificate of Immunization Compliance Form No. 121 is used to meet the immunization requirements for attendance or employment in Mississippi schools or child care facilities. It must be filled out and signed by an issuing individual or validated by MIIX. Keep the completed form in a permanent file accessible to representatives of the Mississippi State Department of Health.
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How do I fill this out?
To fill out the Mississippi Certificate of Immunization Compliance Form No. 121, you will need to provide the necessary personal and immunization information. Ensure that all required fields are completed accurately, and the form is signed by the issuing individual. Follow the detailed instructions provided later on this webpage for each specific field.
How to fill out the Mississippi Certificate of Immunization Compliance Form No. 121?
1
Enter the child's name and date of birth.
2
Provide the parent or guardian's name and address.
3
Fill in the dates for each required vaccine dose received by the child.
4
Check the appropriate box for the immunization requirements met.
5
Sign and date the form, or have it validated by MIIX.
Who needs the Mississippi Certificate of Immunization Compliance Form No. 121?
1
Parents: To ensure their child meets the immunization requirements for school or child care entry.
2
Health Care Providers: To certify a child's immunization status for school or child care attendance.
3
School Administrators: To verify that students meet the immunization requirements for attendance.
4
Child Care Operators: To ensure that children under their care are properly immunized.
5
Employers: To verify that employees meet the immunization requirements for employment.
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On PrintFriendly, you can effortlessly edit the Mississippi Certificate of Immunization Compliance Form No. 121 using our intuitive PDF editor. Simply upload the form and make the necessary changes to the required fields. Save your edited form when you're finished, ensuring all information is accurate.
1
Upload the Mississippi Certificate of Immunization Compliance Form No. 121 on PrintFriendly.
2
Enter the required personal and immunization information into the appropriate fields.
3
Check for accuracy and completeness of all entered information.
4
Use the e-signature tool to sign the form if needed.
5
Save the edited form for submission or record-keeping.
What are the instructions for submitting this form?
To submit the Mississippi Certificate of Immunization Compliance Form No. 121, ensure all required fields are filled out and the form is signed or validated. Submit the completed form to the child's school, child care facility, or employer. For any further assistance, contact the Mississippi State Department of Health. Advice: Keep a copy of the completed form for your records and follow up with the institution to confirm receipt.
What are the important dates for this form in 2024 and 2025?
The Mississippi Certificate of Immunization Compliance Form No. 121 must be updated for the upcoming school year by the start of enrollment. Ensure that all immunization records are current and the form is signed or validated before submission.
What is the purpose of this form?
The Mississippi Certificate of Immunization Compliance Form No. 121 is a mandatory document required to confirm an individual's immunization status for school or child care attendance in Mississippi. This form ensures that children and employees are protected against preventable diseases. By completing and submitting this form, parents, health care providers, and institutions contribute to public health and safety.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The full name of the child or individual receiving the immunization compliance.
- 2. Date of Birth: The birth date of the individual in MM/DD/YY format.
- 3. Name of Parent: The full name of the parent or guardian.
- 4. Address: The residential address including street, city, state, and zip code.
- 5. Vaccine Doses: Dates of each required vaccine dose in MM/DD/YY format.
- 6. Compliance Check: Checkboxes to indicate compliance with various immunization requirements.
- 7. Medical Exemption: Checkbox for attaching Medical Exemption Form 122, if applicable.
- 8. Serological Confirmation: Date of serological confirmation of immunity, if applicable.
- 9. Issuing Individual: Name and signature of the issuing individual or validation by MIIX.
- 10. Expiration Date: Expiration date of the form in MM/DD/YY format.
What happens if I fail to submit this form?
Failure to submit the Mississippi Certificate of Immunization Compliance Form No. 121 can result in non-compliance with state regulations for school or child care attendance. This may lead to an individual being denied entry to these institutions.
- School Entry Denial: Students without a valid form may be denied entry to schools.
- Child Care Entry Denial: Children without a valid form may be denied entry to child care facilities.
- Employment Issues: Employees without proof of immunization may face employment hurdles.
How do I know when to use this form?
- 1. School Enrollment: When enrolling a child in a Mississippi school.
- 2. Child Care Enrollment: When enrolling a child in a child care facility.
- 3. Student Transfer: When transferring a student to a Mississippi school from out-of-state.
- 4. Immunization Updates: When updating immunization records for existing students.
- 5. Employment Compliance: When verifying immunization compliance for employment purposes.
Frequently Asked Questions
What is the Mississippi Certificate of Immunization Compliance Form No. 121?
It is a form used to verify that an individual meets the immunization requirements for school or child care attendance in Mississippi.
How do I fill out the Mississippi Certificate of Immunization Compliance Form No. 121?
Provide the child's personal and immunization information, ensure all required fields are completed, and sign the form.
Who needs to use this form?
Parents, health care providers, school administrators, child care operators, and employers need this form to verify immunization compliance.
Can I edit the form on PrintFriendly?
Yes, you can easily edit the form using PrintFriendly’s PDF editor.
How do I sign the form on PrintFriendly?
Use the e-signature tool in PrintFriendly’s PDF editor to add your electronic signature.
How can I share the form using PrintFriendly?
After completing and saving the form, use PrintFriendly’s sharing options to email or generate a shareable link.
What information do I need to fill out the form?
You will need the child's name, date of birth, parent or guardian's name and address, and dates of received vaccine doses.
When should I use this form?
Use this form when enrolling a child in school or child care, or when verifying immunization compliance for employment.
What should I do if I make a mistake on the form?
You can use PrintFriendly’s PDF editor to correct any mistakes before saving the form.
Do I need a health care provider to sign the form?
Yes, the form must be signed by an issuing individual or validated by MIIX.
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