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 December 15, 2021, effective February 14, 2022 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 or university 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 online or by correspondence only.
D. Delegated physician assistant – a licensed physician assistant authorized under section 12-240- 107 (6), C.R.S., to execute Certificates of Immunization, Certificates of Medical exemptions and/or supervise a public health or school nurse, as authorized by part 9 of article 4 of title 25, C.R.S.
E. Department (the) – the Colorado Department of Public Health and Environment.
F. Dose - a measured quantity of an immunizing agent; quantity and frequency of administration determined by recognized health authorities and the manufacturer of each agent.
G. Emancipated student - any student who has reached 18 years of age; 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.
H. Immunization information system - a comprehensive immunization tracking system the Department is required to maintain pursuant to section 25-4-2403(2), C.R.S. that enables the collection of epidemiological information from the sources delineated in section 25-4-2403(2), C.R.S. and the investigation and control of communicable diseases. Individuals, parents and legal guardians may provide information to the immunization information system; however, pursuant to section 25-4-2403(7), C.R.S., they have the option to exclude their or their student’s immunization information from the immunization information system at any time.
I. 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.
J. 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.
K. In-process student - a student may be considered in-process if:
1. Within fourteen days after receiving direct personal notification that the Certificate of Immunization 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 ACIP. If the student does not fulfill the plan, the student shall be suspended or expelled from school for noncompliance per 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. College or university students, as defined in section I (C), present to the appropriate school official 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 enroll, remain enrolled, or audit 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 18 years of age or older.
L. Nonmedical exemption - an immunization exemption based upon a religious belief whose teachings are opposed to immunizations or a personal belief that is opposed to immunizations.
M. Parent - the person or persons with parental or decision-making responsibilities for a child.
N. Practitioner - a duly licensed physician, advanced practice nurse, or other person who is permitted and otherwise qualified to administer vaccines under Colorado law.
O. School - all child care facilities licensed by the Colorado Department of Human Services including: child care centers, school-age child care centers, 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(30), C.R.S., a guest child care facility as defined in section 26-6-102(16), C.R.S., a ski school as defined in section 26-6-103.5 (6), C.R.S., or college or university classes which are: offered off-campus; offered to nontraditional adult students as defined by the governing board of the institution; offered at colleges or universities which do not have residence hall facilities, or; a school whose normal course of student instruction is delivered online only.
P. School health authority - an individual working for or on behalf of the child care facility or school who is knowledgeable about child care/school immunizations.
Q. School official - the school’s chief executive officer or any person designated by him/her as his/her representative.
R. Student - any person enrolled in a Colorado school as defined in section I (O), except:
1. A child who enrolls and attends a licensed child care center, as defined in section 26-6- 102(5), C.R.S., which is located at a ski area, for up to fifteen days or less in a fifteen- consecutive-day period, no more than twice in a calendar year, with each fifteen- consecutive-day period separated by at least sixty days, and 2. College and university students as defined in section I (C).
S. Titer – laboratory test that measures the presence and amount of antibodies in blood. Antibody titers can be used to show that a person is immune to some diseases.
T. Up-to-date - all school-required vaccines have been administered to the student in accordance with Section II.
II. Minimum Immunization Requirements A. To attend school, a student must have an up-to-date Certificate of Immunization with the dates and types of immunizations administered. Meeting the initial immunization requirements does not exempt a student from meeting subsequent requirements. This certificate must demonstrate immunization against the following diseases:
1. Hepatitis B 2. Pertussis 3. Tetanus 4. Diphtheria 5. Haemophilus Influenzae Type B (HIB)
6. Pneumococcal disease 7. Polio 8. Measles 9. Mumps 10. Rubella 11. Varicella B. Except as required in paragraphs (C) and (D) of this Section II, when healthcare providers administer the immunizations identified in Paragraph (A) of this Section II, the immunizations will be administered according to the schedule established by the ACIP, as authorized in section 25- 4-902(1)(a), C.R.S.
C. Students between the ages of 4 through 6 years are required to receive their final doses of Diphtheria, Tetanus, and Pertussis (DTaP), Inactivated Polio Vaccine (IPV), Measles, Mumps, and Rubella (MMR) and Varicella prior to kindergarten entry.
D. Students are required to receive Tetanus, Diphtheria, Pertussis (Tdap) prior to 6th grade entry. One dose of Tdap is required for 6th through 12th grades.
E. Laboratory confirmation of positive titers are an acceptable alternative to the following vaccines when submitted to the student’s school: DTaP, Hepatitis B, Varicella and MMR. For DTaP substitution, both the diphtheria and tetanus titers must be positive. For MMR substitution, titers for measles, mumps, and rubella must be positive. A titer is not an acceptable replacement for Haemophilus Influenzae type b, Pneumococcal, IPV, or Tdap vaccines.
III. Exemptions from Immunization A parent or legal guardian shall have their student immunized, unless the student is exempted. An emancipated student or a student eighteen years of age or older shall have themselves immunized, unless the student is exempted. A student is exempted from receiving the required immunizations when the requirements of either Paragraph A or B of this Section III are met.
A. Medical exemption - A student obtains a medical exemption from one or more immunization requirements through submission of the Department’s Certificate of medical exemption completed and signed by an advanced practice nurse, a delegated physician assistant, 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 one or more immunizations would endanger their life or health or is medically contraindicated due to other medical conditions. This form is to be submitted once, unless the student’s information or school changes, and must be maintained on file at each new school the student attends.
B. Nonmedical exemption - A student obtains a nonmedical exemption from one or more immunization requirements through submission of the Department’s Certificate of nonmedical exemption signed by one parent or legal guardian, an emancipated student, or a student eighteen years of age or older. A completed Certificate of nonmedical exemption must also include either:
1. The signature of a person who is authorized pursuant to Title 12 to administer immunizations within their scope of practice, or 2. Confirmation of completion of the Department’s online education module described in Section XII of this rule.
3. Frequency of submission:
C. In the event of a disease outbreak for 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.
D.
1. Immunization records of each student participating in a nonpublic home-based education program pursuant to Section 22-33-104.5, C.R.S., shall be maintained on a permanent basis by the parent in charge and in control of said program, and are required to be submitted:
2. A school district that is exercising its authority pursuant to Section 22-33-104.5(3)(G) or an independent school organized pursuant to Section 22-33-104 (2)(B) where students are enrolled but do not attend is entitled to only:
E. All information distributed to parent(s) by school districts regarding immunizations shall inform them of their rights in Section III (A-D).
IV. Examination and audit of official school immunization records The Department’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), legal guardian, emancipated student, or student 18 years of age or older was informed of the deficiencies in the student’s official school immunization records pursuant to section I (K) (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), legal guardian, emancipated student, or student 18 years of age or older 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), legal guardian or student within 7 calendar days of the finding and the student shall: a) provide proof of immunization within 14 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 is attending a school that is not subject to the School Attendance Law, section 22- 33-101 et seq., C.R.S., school officials shall take appropriate action to deny attendance to the student in accordance with that school’s procedures or contract with the student. No indigent child shall be excluded, suspended, or expelled from school unless the immunizations have been available and readily accessible to the indigent child at public expense.
VI. Official school immunization records A. Official school immunization records shall include:
1. The Department’s Certificate of Immunization or an Alternate Certificate of Immunization approved by the Department, which includes one of the following forms of documentation:
2. The Department’s Certificate of medical exemption, and 3. The Department’s Certificate of nonmedical exemption.
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, delegated physician assistant, 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 Certificate of Immunization, except that the Department may waive transfer requirements for select states’ Certificates of immunization the Department recognizes to be consistent with Colorado’s Certificate of Immunization.
C. Schools shall have on file an official school immunization record for every student enrolled. The official school immunization record 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. Annually, by January 15 of each year, any child care center, preschool or head start program that is licensed by the Colorado Department of Human Services to provide care to ten or more children and are not exempt from reporting pursuant to section VII (B), and; public, private, or parochial schools with kindergarten, elementary or secondary schools through grade twelve, shall send aggregate immunization and exemption data, by antigen, to the Department. Required 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 section II;
3. Total number of students and total number of kindergarten students who have a medical exemption for all immunizations, as required in section II;
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 section II;
5. Total number of students and total number of kindergarten students who have a nonmedical exemption for all immunizations, as required in section II;
6. Total number of students and total number of kindergarten students who have a nonmedical exemption for one or more but not all immunizations, as required in section II;
7. Total number of in-process students and total number of in-process kindergarten students;
8. Total number of students and total number of kindergarten students not up-to-date for immunizations, as required in section II, with no exemption on file, and not in-process; and 9. Total number of students and total number of kindergarten students with no immunization records.
B. Schools not required to send aggregate immunization and exemption data to the Department include: K-12th grade schools whose normal course of schooling is online only, school-age child care centers, family child care homes, drop-in centers, day treatment centers, foster care homes, day camps, and resident camps.
VIII. Notification of noncompliance A. Section 25-4-907, C.R.S. requires that if a student is suspended or expelled from school for failure to comply with the immunization law, the school official shall notify the Department, or county, district, or municipal public health agency who shall then contact the parent(s) or emancipated student in an effort to secure compliance so that the student may be re-enrolled in school.
B. Upon receipt of an immunization referral from the school, the Department, or county, district, or municipal public health agency shall contact the parent(s) or legal guardian(s) of the referred student, the emancipated student or student 18 years of age and older to offer immunization and secure compliance with the school immunization law.
IX. Requirements for college and university students, colleges and universities. The provisions below apply only to colleges or universities, or students enrolled in a college or university.
A. Minimum immunization requirements 1. Two valid doses of the MMR vaccine are required for all college or university students, unless the college or university student was born before 1957.
2. Pursuant to section 25-4-901, C.R.S. et. seq., and section 23-5-128 (3), C.R.S., each college and university shall provide information concerning meningococcal disease and meningococcal vaccine to each new college or university student residing in student housing, or if the college or university student is under 18 years, to the college or university student’s parent or legal guardian. College and university students residing in student housing who have not received a meningococcal vaccine within the last five years shall review the information concerning meningococcal disease and meningococcal vaccine. If the college or university student does not obtain a vaccine, a signature must be obtained from the college or university student or if the college or university student is under 18 years, the college or university student’s parent or legal guardian indicating that the information was reviewed and the college or university student or college or university student’s parent or guardian has declined the vaccine.
B. Exemptions from immunization A college or university student is exempted from receiving required immunizations in the following manner:
1. Medical exemption - A student obtains a medical exemption through the submission of the Department’s Certificate of medical exemption completed and signed by an advanced practice nurse, a delegated physician assistant, 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 college or university student is such that one or more immunizations would endanger their life or health or are medically contraindicated due to other medical conditions. This form is to be submitted once, unless the student’s information or school changes, and must be maintained on file at each new school the student attends.
2. Nonmedical exemption - A student obtains a nonmedical exemption through the submission of the Department’s Certificate of nonmedical exemption signed by the college or university student 18 years of age or older, emancipated college or university student, or the parent or legal guardian if the college or university student is under 18 years of age. Beginning with college or university entry, the Department’s Certificate of nonmedical exemption must be submitted at enrollment. A Certificate of nonmedical exemption must also include either:
3. In the event of a disease outbreak for 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.
C. Examination and audit of official school immunization records The Department’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 college or university student not in full compliance shall be denied attendance from school according to the rules in section IX (D).
D. Denial of attendance 1. A college or university student who is: not in-process, not appropriately vaccinated for their age, or not exempt shall be denied attendance in accordance with the law.
2. A school official shall deny attendance from school, pursuant to the provisions established by the school, any college or university student not in-process, not appropriately immunized for their age, or not exempt per section 25-4-903, C.R.S. No college or university student shall be denied attendance for failure to comply unless there has been a direct personal notification of noncompliance by the appropriate school authority to the college or university student's parent or guardian, the emancipated college or university student or the college or university student 18 years of age or older.
E. Official school immunization records 1. Official school immunization records shall include:
2. Schools shall have on file an official school immunization record for every college or university student enrolled.
F. Reporting of statistical information – Annually, by January 15 of each year, any college or university that constitutes a school as defined by section I (O) shall send aggregate immunization and exemption data, by antigen, to the Department.
Required data shall include:
1. Total number of college or university students enrolled in the school;
2. Total number of college or university students who are up-to-date with immunizations, as required in this section (IX);
3. Total number of college or university students who have a medical exemption for the MMR vaccine;
4. Total number of college or university students who have a nonmedical exemption for the MMR vaccine;
5. Total number of in-process college or university students;
6. Total number of college or university students who have a signed waiver for the Meningococcal vaccine;
7. Total number of college or university students not up-to-date for the MMR vaccine, with no exemption on file, no Meningococcal vaccine waiver on file, and not in-process; and 8. Total number of college or university students with no immunization records.
X. Contract Requirements for Providers, Hospitals, and Health Care Clinics to be an Agent of the Department for the Purposes of the Immunization Program A. To be an agent of the Department for the purposes of administering immunizations to infants, children, and students, a provider, hospital, or health care clinic must provide each patient receiving a vaccine, or the parent or legal guardian, if the patient is an unemancipated minor, a copy of the currently approved Vaccine Information Statement, as required by federal law.
B. The Department shall make such requirements as are necessary to assure the confidentiality and security of information in immunization information system operated pursuant to section 25-4- 2403(3), C.R.S.
XI. Fee for the Administration, Reporting, and Tracking of Vaccine This section applies to immunizations provided by the Department that are recommended by the ACIP and available 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 provided by the Department.
B. A vaccine recipient may not be denied vaccine provided by the Department 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 A. Per section 25-4-903 (2.5 and 2.7), C.R.S., the Department shall provide immunization information to the public via an online education module that fairly presents both the benefits and risks of immunizations. The immunization information and contents of this module shall include, but are not limited to:
1. Exemption rates in Colorado that are available to the public through the Department, 2. Evidence-based research, 3. Resources and information from credible scientific and public health organizations, 4. Peer-reviewed studies, and 5. Data concerning the risk of immunization injury.
B. The module shall be interactive such that the viewer of the module must engage with the content successfully to receive a certificate of completion.
C. Upon successful completion of the module, a Certificate of nonmedical exemption that includes confirmation of completion of the Department’s online education module will be electronically generated for downloading and printing.
D. The online learning module shall not require a parent or legal guardian, emancipated student, or student eighteen years, of age or older to sign or indicate agreement with any language regarding immunizations that may be contrary to a religious belief or personal belief that is opposed to immunizations in order to complete the online learning module. XIII. Vaccinated Children Standard A. Per Section 25-4-911 (1), C.R.S., the goal for every school is for 95% of the enrolled student population to be vaccinated with each vaccine required for school entry in Section II in order to reduce the spread of vaccine-preventable disease and protect the health of all people in the school community, including students who cannot be immunized for medical reasons.
XIV. Annual Parent Letter A. Per Section 25-4-902 (4), C.R.S., annually, by January 15 of each year, the Department shall develop and provide to the Department of Education and the Department of Human services a standardized document regarding immunizations. The standardized document shall be updated annually and must include, but not be limited to:
1. A list of the immunizations required for enrollment in a school and the age at which the immunization is required;
2. A list of immunizations currently recommended for children by the ACIP and the recommended age at which each immunization should be given;
3. A place on the document where a school can include the school’s specific immunization and exemption rates for the MMR vaccine and for every other vaccine for the school’s enrolled student population from the prior school year compared to the vaccinated children standard described in Section 25-4-911, C.R.S.; and 4. A statement that the school is required to collect and report the information pursuant to Section 25-4-902 (4)(a), C.R.S., and that the school does not control the school’s specific immunization and exemption rates or establish the vaccinated children standard described in Section 25-4-911, C.R.S.
B. Annually, by January 31 of each year, the Department of Education and the Department of Human Services shall post this standardized document on their websites.
C. Annually, by February 15 of each year, a school shall directly distribute the document to the parent or legal guardian of each student enrolled in its school, emancipated students, or students eighteen years of age or older, consistent with Section 25-4-903 (5), C.R.S.
1. The school shall include on the document the school's specific immunization and exemption rates for the measles, mumps, and rubella vaccine for the school's enrolled student population for the prior school year compared to the vaccinated children standard described in Section 25-4-911, C.R.S.
2. The school may include on the document the school's specific immunization and exemption rates for any other vaccine for the school's enrolled student population for the prior school year.
_________________________________________________________________________ Editor’s Notes History Rule I, Table 1, Table 2 eff. 03/01/2008.
Rule I, Table 1 eff. 03/02/2009.
Rules I-XI, Table 1 eff. 12/30/2010.
Rules I.L., II. A., Table 1 eff. 07/01/2012.
Rule XI emer. rule eff. 01/16/2013.
Rule XI, Table 1, Table 2 eff. 04/14/2013.
Rules I-IV, VI, IX, XI eff. 10/15/2014. Table 1, Table 2 repealed eff. 10/15/2014. Rules I-VII, XII eff. 07/01/2015.
Rules I-IX eff. 10/15/2015. Rules III.C-D repealed eff. 10/15/2015. Rules II, III, VII, IX eff. 07/15/2016.
Rules I.C-IV.A, VI.A-VII.A.11, IX.A.1, IX.E-F eff. 07/30/2017. Entire rule eff. 08/14/2018.
Rules I-IV, VI-X, XII-XIV eff. 01/14/2021.
Rules III.D-E eff. 02/14/2022. Rule III.B.4 repealed eff. 02/14/2022.