6 CCR 1009-2
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT THE INFANT IMMUNIZATION PROGRAM AND IMMUNIZATION OF STUDENTS ATTENDING SCHOOL 6 CCR 1009-2 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Adopted by the Board of Health on April 15, 2015 I. Definitions A. Advisory Committee on Immunization Practices (ACIP) - a group of medical and public health experts that develops recommendations on how to use vaccines to control diseases in the United States. ACIP was established under Section 222 of the Public Health Service Act (42 U.S.C. § 217a).
B. Child - any student less than 18 years of age.
C. College student - any student who is enrolled for one or more classes at a college or university and who is physically present at the institution. This includes students who are auditing classes but does not include persons taking classes by correspondence only.
D. Dose - a measured quantity of an immunizing agent; quantity and frequency of administration determined by recognized health authorities and the manufacturer of each agent. (partial, “split,” half or fractionated “doses” are not acceptable for certification.).
E. Emancipated student - any student who has reached age 18; a lawfully married child of any age; a child 15 years of age or older who is managing his/her own financial affairs and who is living separate and apart from his/her parent.
F. Immunization tracking system - a comprehensive immunization tracking system established by the Department of Public Health and Environment pursuant to Section 25-4-2403, C.R.S.
G. Indigent child - any child whose parent cannot afford to have the child immunized or if emancipated, who cannot himself/herself afford immunization and who has not been exempted.
H. Infant - any child up to twenty-four months of age or any child eligible for vaccination and enrolled under the Colorado Medical Assistance Act, Articles 4, 5, AND 6 of Title 25.5 C.R.S.
I. In-process student - a student may be considered in-process if:
1. Within fourteen days after receiving direct personal notification that the certificate is not up-to date according to the requirements of the state board of health, the parent or emancipated student submits documentation that the next required immunization has been given and a signed written plan for obtaining the remaining required immunizations. The scheduling of immunizations in the written plan shall follow medically recommended minimum intervals consistent with the U.S. Public Health Service Advisory Committee on Immunization Practices. If the student does not fulfill the plan, the student shall be suspended or expelled from school for non-compliance as noted in Section 25-4-907, C.R.S. if the next dose is not medically indicated within fourteen days, then the medically approved minimum intervals would apply.
2. With regards to college or university students as defined in Section I Provision C and O, the student must present to the appropriate official of the school either (I) a signed written authorization requesting local health officials to administer required immunizations or (II) a plan for receipt of the required immunization or the next required immunization in a series within either 30 days or the medically approved minimum interval. If this does not occur, the college or university student will not be allowed to register for the current term or session. Such written authorizations and plans must be signed by one parent or guardian or the emancipated student or the student eighteen years of age or older.
J. Parent - the person or persons with parental or decision-making responsibilities for a child.
K. Practitioner - a duly licensed physician, advanced practice nurse, or other person who is permitted and otherwise qualified to administer vaccines under the laws of this state.
L. School - all child care facilities licensed by the Colorado Department of Human Services including: child care centers, school-age child care center, preschools, day camps, resident camps, day treatment centers, family child care homes, foster care homes, and head start programs; public, private, or parochial kindergarten, elementary or secondary schools through grade twelve, or a college or university. Schools do not include a public services short-term child care facility as defined in section 26-6-102 (6.7), C.R.S., a guest child care facility as defined in section 26-6-102 (5), C.R.S., a ski school as defined in section 26-6-103.5 (6), C.R.S., or college or university courses which are offered off-campus; or are offered to nontraditional adult students, as defined by the governing board of the institution; or are offered at colleges or universities which do not have residence hall facilities.
M. School health authority - an individual working for or on behalf of the child care facility or school who is knowledgeable about childcare/school immunizations.
N. School official - the school’s chief executive officer or any person designated by him/her as his/her representative.
O. Student - any person enrolled in a Colorado school as defined in I (L).
II. Exemptions from Immunization It is the responsibility of the parent(s) to have his or her child immunized unless the child is exempted. A student may be exempted from receiving the required immunizations in the following manner:
A. Medical exemption - By submitting a medical exemption form with the statement of medical exemption signed by an advanced practice nurse or physician licensed to practice medicine or osteopathic medicine in any state or territory of the United States indicating that the physical condition of the student is such that immunizations would endanger his/her life or health or is medically contraindicated due to other medical conditions. This form is to be submitted once, and must be maintained on file at each new school the student attends.
B. Religious exemption - By submitting a nonmedical exemption form signed by the parent(s) or the emancipated student indicating that the parent(s) or emancipated student is an adherent to a religious belief whose teachings are opposed to immunizations. Beginning July 1, 2016, 1. Prior to kindergarten entry, a nonmedical exemption form must be submitted at each interval in the 2015 ACIP Birth-18 years immunization schedule at which immunizations are due. The 2015 ACIP immunization schedule is incorporated in III.B. This documentation is required only for those vaccines required to prevent the diseases listed in Section III, Provision A.
2. From kindergarten through twelfth grade, a nonmedical exemption form must be submitted once per school year.
3. Beginning with college or university entry, a nonmedical exemption form must be submitted at enrollment.
C. Personal belief exemption - By submitting a nonmedical exemption form signed by the parent(s) or the emancipated student indicating that the parent(s) or emancipated student has a personal belief that is opposed to immunizations.
Beginning July 1, 2016, 1. Prior to kindergarten entry, a nonmedical exemption form must be submitted at each interval in the 2015 ACIP Birth-18 years immunization schedule at which immunizations are due. The 2015 ACIP immunization schedule is incorporated in III. B. This documentation is required only for those vaccines required to prevent the diseases listed in Section III., Provision A.
2. From kindergarten through twelfth grade, a nonmedical exemption form must be submitted once per school year.
3. Beginning with college or university entry, a nonmedical exemption form must be submitted at enrollment.
D. In the event of an outbreak of disease against which immunization is required, no exemption or exception from immunization shall be recognized and exempted persons may be subject to exclusion from school and quarantine.
E. All information distributed to the parent(s) by school districts regarding immunization shall inform them of their rights under Section II, Provisions A through C.
F. If the school chooses to use the immunization tracking system to monitor compliance with the school law, and the parent(s) or student submits an exemption, the school must submit the exemption information to the immunization tracking system.
III. Minimum Immunization Requirements A. To attend school, a student must have an age- or grade-appropriate Certificate of Immunization. Initial certification does not exempt a student from meeting subsequent age or grade requirements. This certificate must demonstrate immunization against the following diseases:
1. Hepatitis B 2. Pertussis 3. Tetanus 4. Diphtheria 5. Haemophilus Influenza Type B (HIB)
6. Pneumococcal disease 7. Polio 8. Measles 9. Mumps 10. Rubella 11. Varicella B. The minimum number of doses required by level of school/age of student is set forth in the 2015 Birth – 18 Years Recommended Immunization Schedule or the 2015 Catch-Up Immunization Schedule of the Advisory Committee on Immunization Practices (ACIP).
1. The 2015 ACIP Birth-18 Years Recommended Immunization Schedule (Schedule) is incorporated by reference for only those vaccines required to prevent the diseases listed in Section III, Provision A. Other immunizations included in the ACIP recommendations are not required. This schedule is posted on the Centers for Disease Control and Prevention website at: http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs- child-combined-schedule.pdf, or on the Colorado Department of Public Health and Environment website at [www.coloradoimmunizations.com], and, is available for public inspection during regular business hours at the Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, Denver, Colorado 80246. Copies of the recommended schedules are available from the Colorado Department of Public Health and Environment for a reasonable charge that comports with the department’s record request practices. This rule does not include any later amendments or editions of the ACIP Schedule.
2. In addition, the 2015 ACIP Catch-Up Immunization Schedule is incorporated by reference for those children not fully immunized and only for those vaccines required to prevent the diseases listed in Section III, Provision A. Other immunizations included in the ACIP recommendations are not required. This recommended schedule is posted on the Centers for Disease Control and Prevention website at http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined- schedule.pdf, or on the Colorado Department of Public Health and Environment website at [www.coloradoimmunizations.com], and, is available for public inspection during regular business hours at the Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, Denver, Colorado 80246. Copies of the recommended schedules are available from the Colorado Department of Public Health and Environment for a reasonable charge that comports with the department’s record request practices. This rule does not include any later amendments or editions of the ACIP Catch-Up Schedule.
C. Information concerning meningococcal disease and the meningococcal vaccine shall be provided to each new college or university student residing in student housing, or if the student is under 18 years, to the student’s parent or guardian. If the student does not obtain a vaccine, a signature must be obtained from the student or if the student is under 18 years, the student’s parent or guardian indicating that the information was reviewed.
D. Two valid doses of the measles, mumps and rubella vaccine are required for all college or university students, unless the college or university student was born before 1957.
IV. Examination and Audit of Official School Immunization Records The Department of Public Health and Environment’s representative shall have the right to audit and verify records to determine compliance with the law. Discrepancies found through audits shall be corrected by school officials, and any student not in full compliance shall be suspended or expelled from school according to the following rules:
A. If the parent(s) or emancipated student was informed of the deficiencies in the student’s official school immunization records pursuant to Section I, Provision I.1 of the rules, the student shall be suspended or expelled pursuant to Section 25-4-907, C.R.S.
B. If the parent(s) or emancipated student was not informed by a direct personal notification of the immunizations required and alternatives for compliance with the law, the school shall notify the parent(s) or emancipated student within 7 calendar days of the finding and the student shall: a) provide proof of immunization within fourteen days, b) continue as an in-process student, c) verify that the student is exempt, or d) the student shall be suspended or expelled pursuant to Section 25-4-907, C.R.S.
V. Denial of Attendance A. A student who is: not in-process, not appropriately vaccinated for his/her age, or not exempt shall be denied attendance in accordance with the law.
B. If the student or child is attending a school which is not subject to the School Attendance Law, Section 22-33-101 et seq., C.R.S., the school officials shall take appropriate action to deny attendance to the student or child in accordance with that school’s procedures or contract with the student; the college student will not be allowed to register for the current term or session. No indigent child shall be excluded, suspended, or expelled from school unless the immunizations have been available and readily accessible to the child at public expense.
VI. Official School Immunization Records A. Official school immunization records shall include:
1. An official Certificate of Immunization or an Alternate Certificate of Immunization that has been approved by the Department of Public Health and Environment shall include one of the following forms of documentation that include the dates and types of immunizations administered to a student:
2. An official medical exemption form with the date and vaccines exempted from, or 3. An official nonmedical exemption form with the date, type of exemption taken and the vaccines exempted from.
B. Any immunization record (original or copy) provided by a physician licensed to practice medicine or osteopathic medicine in any state or territory of the United States, registered nurse, or public health official may be accepted by the school official as proof of immunization. The information is to be verified by the school official and transferred to an official Colorado Certificate of Immunization.
C. Schools shall have on file an official Certificate of Immunization for every student enrolled. The Certificate of Immunization will be kept apart from other school records. When a student withdraws, transfers, or is promoted to a new school, the school official shall return the Certificate of Immunization to the parent(s) or emancipated student upon request or transfer it with the student’s school records to the new school. Upon a college or university student’s request, the Certificate of Immunization shall be forwarded as specified by the student.
VII. Reporting of Statistical Information A. On December 1, 2016, and each year thereafter, all schools shall send aggregate immunization and exemption data by antigen to the department of public health and environment. This data shall include:
1. Total number of students and total number of kindergarten students enrolled in the school;
2. Total number of students and total number of kindergarten students who are up-to-date with immunizations as required in part III;
3. Total number of students and total number of kindergarten students who have a medical exemption for all immunizations as required in part III;
4. Total number of students and total number of kindergarten students who have a medical exemption for one or more but not all immunizations as required in part III;
5. Total number of students and total number of kindergarten students who have a religious exemption for all immunizations as required in part III;
6. Total number of students and total number of kindergarten students who have a religious exemption for one or more but not all immunizations as required in part III;
7. Total number of students and total number of kindergarten students who have a personal belief exemption for all immunizations as required in part III;
8. Total number of students and total number of kindergarten students who have a personal belief exemption for one or more but not all immunizations as required in part III;
9. Total number of in-process students and total number of in-process kindergarten students;
10. Total number of students and total number of kindergarten students not up-to-date for immunizations as required in part III, with no exemption on file, and not in-process; and 11. Total number of students and total number of kindergarten students with no immunization records.
B. The requirements delineated in provision VII.A. do not apply to a college or university. On December 1 of each year, college and university officials shall send the immunization summary report to the department of public health and environment. VIII. Notification of Public Health Department A. Section 25-4-907, C.R.S. requires that if a child is suspended or expelled from school for failure to comply with the immunization law, the school official shall notify the state or local department of health or public health nurse who shall then contact the parent(s) or emancipated student in an effort to secure compliance so that the child may be re-enrolled in school.
B. Upon receipt of an immunization referral from the school the public health department or public health nurse shall contact the parent(s) of the referred child or the emancipated student himself/herself to offer immunization and to secure compliance with the school immunization law in order that the child may provide a completed Certificate of Immunization to the school and in the case of an expelled or suspended child, be re-enrolled in school.
IX. Purchase, Storage, and Distribution of Vaccines As necessary to comply with Section 25-4-905, C.R.S., the Department of Public Health and Environment shall assure the purchase, storage, and distribution of the vaccines included in, but not limited to these rules.
X. Contract Requirements for Providers, Hospitals, and Health Care Clinics to be an Agent of the Department of Public Health and Environment for the Purposes of the Immunization Program A. To be an agent of the Department of Public Health and Environment for the purposes of administering immunizations to infants, children, and students, a provider, hospital, or health care clinic must agree to provide each patient receiving a vaccine, or the parent or legal guardian if such patient is an unemancipated minor, a copy of the currently approved vaccine information statement.
B. The Department of Public Health and Environment shall make such requirements as are necessary to assure the confidentiality and security of information in an immunization tracking system operated pursuant to Section 25-4-1705(5)(e)(I)(H), C.R.S and Section 25-4-1705(7), C.R.S.
XI. Fee for the Administration, Reporting, and Tracking of Vaccine This rule applies to immunizations purchased by CDPHE that are recommended by the Advisory Committee on Immunization Practices of the U.S. Department of Health and Human Services and provided to Colorado practitioners.
A. Practitioners may charge up to the Centers for Medicare and Medicaid services maximum regional fee for the administration of vaccine. These fees apply to all vaccines purchased by CDPHE, including but not limited to the Infant Immunization Program, and Immunization of Children Attending School.
B. A vaccine recipient may not be denied vaccine provided by CDPHE because of inability to pay the administration fee.
C. If a practitioner’s vaccine administration costs are less than the Centers for Medicare and Medicaid Services maximum regional fee for the administration of vaccine, then they may only charge up to that lesser amount.
XII. On-line educational module As necessary to comply with section 25-4-903 (2.5), C.R.S., the Department of Public Health and Environment shall provide immunization information to the public. The immunization information and contents of this module shall include, but are not limited to:
A. Exemption rates in Colorado that are available to the public through the Department, B. Evidence-based research, C. Resources and information from credible scientific and public health organizations, and D. Peer-reviewed studies.
_________________________________________________________________________ Editor’s Notes History Section I, Table 1, Table 2 eff. 03/01/2008.
Section I, Table 1 eff. 03/02/2009.
Sections I-XI, Table 1 eff. 12/30/2010.
Rules I.L., II. A., Table 1 eff. 07/01/2012.
Section XI emer. rule eff. 01/16/2013.
Section XI, Table 1, Table 2 eff. 04/14/2013.
Sections I-IV, VI, IX, XI eff. 10/15/2014; Table 1, Table 2 repealed eff. 10/15/2014. Sections I-VII, XII eff. 07/01/2015.