COUNTY OF

Date:
Case Name:
Case Number:
Worker Name:
Worker ID:
Worker Phone Number:
Customer ID:

Instructions for the County:

Give or send this form to the parent or caretaker relative of the child(ren) to take to their child(ren)’s health care provider to fill out.
The parent or caretaker relative can return to the county in-person, by mail, fax or by uploading to their secure electronic account
with the county. The CW 2209 must accompany this form and give adequate information on the child(ren) whose information is
needed and the due date to return the information to the county.

Instructions for Health Care Providers:

The parent or caretaker relative does not have proof of age-appropriate immunizations for their child(ren). This report should
provide the county with an assessment of any medically verifiable condition and duration of the condition that would prohibit
current immunizations or provide proof that the child(ren) has received age-appropriate immunizations.

CHILD ONE
Child’s Name:

Part A - To be completed by health care provider.

Child meets age-appropriate immunizations requirements or has started, but not completed, a series of
immunizations.
Signature of Health Care Provider or Authorized Person: Date:

Part B - To be completed by care provider.

Child should not be immunized due to a medical reason.
Condition and Duration of Condition:

Signature of Health Care Provider or Authorized Person: Date:

Part C - To be completed by parent/caretaker relative.

I do not wish for my child to be immunized because immunization is contrary to my beliefs.
Signature of Parent/Caretaker Relative: Date:

CW 107 (10/2020) Required Form - No Substitutes Permitted

 CHILD TWO
Child’s Name:

Part A - To be completed by health care provider.

Child meets age-appropriate immunizations requirements or has started, but not completed, a series of
immunizations.
Signature of Health Care Provider or Authorized Person: Date:

Part B - To be completed by care provider.

Child should not be immunized due to a medical reason.
Condition and Duration of Condition:

Signature of Health Care Provider or Authorized Person: Date:

Part C - To be completed by parent/caretaker relative.

I do not wish for my child to be immunized because immunization is contrary to my beliefs.
Signature of Parent/Caretaker Relative: Date:

CHILD THREE
Child’s Name:

Part A - To be completed by health care provider.

Child meets age-appropriate immunizations requirements or has started, but not completed, a series of
immunizations.
Signature of Health Care Provider or Authorized Person: Date:

Part B - To be completed by care provider.

Child should not be immunized due to a medical reason.
Condition and Duration of Condition:

Signature of Health Care Provider or Authorized Person: Date:

Part C - To be completed by parent/caretaker relative.

I do not wish for my child to be immunized because immunization is contrary to my beliefs.
Signature of Parent/Caretaker Relative: Date:

CW 107 (10/2020) Required Form - No Substitutes Permitted

 CHILD FOUR
Child’s Name:

Part A - To be completed by health care provider.

Child meets age-appropriate immunizations requirements or has started, but not completed, a series of
immunizations.
Signature of Health Care Provider or Authorized Person: Date:

Part B - To be completed by care provider.

Child should not be immunized due to a medical reason.
Condition and Duration of Condition:

Signature of Health Care Provider or Authorized Person: Date:

Part C - To be completed by parent/caretaker relative.

I do not wish for my child to be immunized because immunization is contrary to my beliefs.
Signature of Parent/Caretaker Relative: Date:

CHILD FIVE
Child’s Name:

Part A - To be completed by health care provider.

Child meets age-appropriate immunizations requirements or has started, but not completed, a series of
immunizations.
Signature of Health Care Provider or Authorized Person: Date:

Part B - To be completed by care provider.

Child should not be immunized due to a medical reason.
Condition and Duration of Condition:

Signature of Health Care Provider or Authorized Person: Date:

Part C - To be completed by parent/caretaker relative.

I do not wish for my child to be immunized because immunization is contrary to my beliefs.
Signature of Parent/Caretaker Relative: Date:

CW 107 (10/2020) Required Form - No Substitutes Permitted