| Document Date: 2014-10-22 22:46:08
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IndustryTerm state law / cost vaccination services / / MedicalCondition Hepatitis A / paralysis / whooping cough / pneumonia / mental retardation / mumps / disease / Chickenpox / seizures / vaccine-preventable disease / Pertussis / arthritis / sterility / measles / chicken pox / serious birth defects / coma / Diphtheria / Tetanus / specific vaccine-preventable diseases / Hepatitis B / Haemophilus Influenza / Polio / vaccine preventable diseases / vomiting / meningococcal disease / rubella / deafness / severe coughing fits / heart failure / liver cancer / diseases / each disease / miscarriage / infection / Cough / illness / infections / serious illness / meningitis / rash / Varicella / joint pain / severe skin infections / sepsis / Initials___________ Date________________ Initials___________ Date________________ Initials___________ Date________________ Measles / / MedicalTreatment immunization / immunizations / vaccination / / Organization Arizona Department of Health Services / ADHS Immunization Program Office / / Position registered nurse / nurse / physician / / ProvinceOrState Arizona / / URL http /
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Arizona law requires that schools, preschools and childcare facilities obtain this form, completed by a physician or registered nurse practitioner, in order for a child to be exempted from immunization requirements for m