3.1 Authority

1. A. These regulations are promulgated pursuant to R.I. Gen. Laws §§16-38-2 and 23-1-18 and are established for the purpose of adopting standards pertaining to requirements for immunizations and testing of communicable diseases for child care workers in preschools and students at any preschool or school in grades Kindergarten-12 and students entering colleges and universities in Rhode Island.

3.2 Incorporated Materials

1. A. These regulations hereby adopt and incorporate the Centers for Disease Control and Prevention (CDC) General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, Recommendations and Reports (January 2011) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations. https://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf
2. B. These regulations hereby adopt and incorporate the "Rhode Island Department of Health Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases" (November 2013) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations. http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/7434.pdf
3. C. These regulations hereby adopt and incorporate the "CDC Guidelines for Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection MMWR, Recommendations and Reports" (June 2000) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations. https://www.cdc.gov/mmwr/PDF/rr/rr4906.pdf
4. D. These regulations hereby adopt and incorporate the "National Resource Center for Health and Safety in Childcare and Early Education's Guidelines for Early Care and Education Programs" (October 2015) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations. http://cfoc.nrckids.org/WebFiles/CFOC3_updated_final.pdf

3.3 Definitions

1. A. Whenever used in these regulations, the following terms shall be construed as follows:

   1. 1. "Advisory Committee on Immunization Practices (ACIP) recommendations", as used in these Regulations, means official federal recommendations for the use of vaccines in the United States and as published by the Centers for Disease Control and Prevention. ACIP recommendations represent the standard of care for vaccination practice in the United States.
   2. 2. "Child care worker" means any person who is temporarily or permanently employed by a preschool (as defined in § 3.3(A)(7) of this Part) who has direct or indirect contact with children in the preschool.
   3. 3. "College" or "university" means any public or private institution of higher learning in the State of Rhode Island.
   4. 4. “Director” means the Director of the Rhode Island Department of Health or his or her duly authorized designee.
   5. 5. “Department” means the Rhode Island Department of Health.
   6. 6. "Entering" means formal registration by a student for attendance at a pre-school, school, college or university in Rhode Island.
   7. 7. “Preschool” means all public and non-public child day-care centers, family day-care homes, nursery schools, or any program licensed or certified by the Department of Children, Youth and Families which provides regular educational services to preschool-aged children in Rhode Island.
   8. 8. “Physician” means an individual licensed under the provisions of R.I. Gen. Laws Chapter 5-37, or an individual licensed to practice allopathic or osteopathic medicine under the laws of another state or territory of the United States, provided those laws are deemed to be substantially equivalent to R.I. Gen. Laws Chapter 5-37.
   9. 9. “R.I. Gen. Laws” means the General Laws of Rhode Island, as amended.
   10. 10. “School” means all public or non-public schools for students in grades Kindergarten through 12 in Rhode Island.
   11. 11. "Student" means any individual who is or has been enrolled, full time or part time, at a preschool or school, and any person entering any public or private college or university in Rhode Island as a: full-time undergraduate or graduate student; part-time undergraduate or graduate student in a health science program who may be in contact with patients. The term “student” shall also include any person from another country attending or visiting classes or educational programs as part of a formal academic visitation or exchange program.
   12. 12. “These Regulations” means all parts of the Rules and Regulations Pertaining to Immunization and Communicable Disease Testing in Preschool, School, Colleges or Universities.
   13. 13. “Waiting period” means the time interval between scheduled doses of vaccine. The length of waiting periods is defined by the ACIP.

3.4 General Requirements

1. A. Preschools and schools shall adopt, at a minimum, the standards of immunization and communicable disease testing in § 3.5 of this Part.

   1. 1. It shall be the responsibility of the administrative head or his/her designee of any preschool or school to secure compliance with these Regulations.

2. B. Colleges and universities shall adopt, at a minimum, the standards of immunization and communicable disease testing contained in § 3.6 of this Part.

   1. 1. It shall be the responsibility of the administrative head, or his/her designee, of any college or university to secure compliance with these Regulations.
3. C. In accordance with ACIP recommendations, for all vaccines discussed in these Regulations, vaccine doses administered less than or equal to four (4) days before the minimum interval or age shall be counted as valid. Doses administered five (5) or more days earlier than the minimum interval or age shall not be counted as valid doses and shall be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval as provided in ACIP recommendations incorporated above at § 3.2(A) of this Part.
4. D. Persons charged with reporting communicable diseases (e.g., physicians, physician assistants, registered nurse practitioners, midwives, laboratories, certified school nurse teachers and other entities or persons) shall comply with the reporting requirements issued by the Department incorporated above at § 3.2(B) of this Part.

3.5 Minimum Standards for Immunization and Communicable Disease Testing for Students Entering Preschools and Schools (K-12)

1. A. Each student, upon initial entry to any preschool or school in Rhode Island, shall furnish evidence to the administrative head of the preschool or school (pursuant to the requirements of § 3.5.3 of this Part) that the student has been immunized, as required in §§ 3.5.1(A)(1)(a) and 3.5.2(A)(1-7) of this Part, unless the student is in an exempt category.

   1. 1. For the immunization requirements stipulated in §§ 3.5.1-(A)(1)(a) and 3.5.2(A) of this Part, a student who is not in compliance with these requirements shall be excluded from attending preschool or school until the requirements are met, unless the student belongs in an exemption category or is in a waiting period between doses as described in § 3.5.4 of this Part.

      3.5.1 Preschool Entry Requirements

2. A. No student shall enter a preschool without an immunization record as defined in § 3.5.3 of this Part documenting that the student has been or is age appropriately immunized in accordance with the current Recommended Childhood Immunization Schedule approved by the Advisory Committee on Immunization Practices (ACIP)/American Academy of Pediatrics(AAP)/American Academy of Family Physicians (AAFP) against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, Haemophilus influenzae type b, hepatitis B, varicella (chickenpox), and pneumococcal disease.

   1. 1. Beginning August 1, 2015, immunization against hepatitis A and rotavirus will be added to the immunizations required pursuant to § 3.5.1 of these Regulations.

      1. a. Beginning August 1, 2015, annual influenza vaccination, given between July 1 and December 31 of each year, is required for all preschool children six to fifty-nine (6-59) months of age.

         3.5.2 School Entry Requirements

3. A. Each student, upon initial entry to any school, shall furnish evidence as required in § 3.5.3 of this Part of having received the vaccines described below:

   1. 1. Diphtheria, Tetanus, and Pertussis Vaccine

      1. a. Five (5) doses of diphtheria, tetanus and acellular pertussis (DTaP) vaccine. If the fourth (4th) dose was given after the fourth (4th) birthday, a fifth (5th) dose is not necessary (total of four (4) doses). Where pertussis vaccine is medically contraindicated, diphtheria-tetanus (DT) vaccine is to be substituted.

         1. (1) Where the student is seven (7) or more years of age and requires additional doses of vaccine to satisfy § 3.5.3(1)(a), Tdap (tetanus-diphtheria-pertussis) or Td (tetanus-diphtheria) shall be given in place of DTaP/DT according to ACIP age appropriate recommendations.
      2. b. One (1) dose of Tdap vaccine is required for students entering seventh (7th) grade (or in the case of an ungraded classroom, for students twelve (12) years of age or older).

   2. 2. Poliomyelitis Vaccine

      1. a. Four (4) doses of any combination of either oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV). The final dose should be given on or after the fourth (4th) birthday. If the third (3rd) dose was given after the fourth (4th) birthday, a fourth (4th) dose is not necessary (total of three (3) doses), if all three (3) doses were either all OPV or all IPV; or a series administered in accordance with ACIP recommendations.
      2. b. For students eighteen (18) years of age and older, poliovirus vaccine is not required.

   3. 3. Measles, Mumps, and Rubella Vaccines

      1. a. Two (2) doses of live measles, mumps and rubella vaccine given at least four (4) weeks apart beginning on or after twelve (12) months of age shall be required for students entering kindergarten (K) and grade seven (7) in accordance with ACIP recommendations.

      2. b. Beginning on August 1, 2015, this requirement shall apply to all students entering grades K through 12 and all students in ungraded classrooms. The following dates are in effect for the grades, as specified below:

         1. (1) August 1, 2014 K,1,2,3,4,5,7,8,9,10,11,12
         2. (2) August 1, 2015 K,1,2,3,4,5,6,7,8,9,10,11,12

   4. 4. Hepatitis B Vaccine

      1. a. Three (3) doses of hepatitis B vaccine administered in accordance with ACIP recommendations are required for students entering grades kindergarten (K) through grade twelve (12) and all students in ungraded classrooms.

   5. 5. Varicella (Chickenpox) Vaccine

      1. a. Two (2) doses of varicella vaccine given at least four (4) weeks apart beginning at or after twelve (12) months shall be required for students entering kindergarten (K) and grade seven (7) (or in the case of an ungraded classrooms, students twelve (12) years of age or older).

      2. b. Beginning on August 1, 2015, this requirement shall apply to all students entering grades K through 12 and all students in ungraded classrooms. The following dates are in effect for the grades, as specified below:

         1. (1) August 1, 2014 K,1,2,3,4,5,7,8,9,10,11,12
         2. (2) August 1, 2015 K,1,2,3,4,5,6,7,8,9,10,11,12

   6. 6. Meningococcal Vaccine

      1. a. All students entering seventh (7th) grade, shall be required to receive one (1) dose of meningococcal vaccine in accordance with ACIP recommendations.

      2. b. Beginning August 1, 2014, this requirement shall apply to all students entering grades seven (7) through twelve (12) and all students in ungraded classrooms. The following dates are in effect for the grades, as specified below:

         1. (1) August 1, 2014 7,8,9,10,11,12
      3. c Beginning August 1, 2015, all students entering grade twelve (12), who had their first dose at age fifteen (15) years or younger, are required to have a booster dose given on or after sixteen (16) years of age.

   7. 7. Human Papillomavirus (HPV) Vaccine

      1. a Beginning August 1, 2015, all students entering seventh (7th) grade shall be required to have at least one (1) dose of the HPV vaccine series.
      2. b Beginning August 1, 2016, all students entering eighth (8th) grade shall be required to have at least two (2) doses of the HPV vaccine series.

      3. c Beginning August 1, 2017, all students entering ninth (9th) grade shall be required to have completed the HPV vaccine series (3 doses).

         3.5.3 Immunization Records

4. A. Acceptable evidence of completion of immunizations shall include the day, month, year and type/name of each dose of vaccine administered. Such evidence shall consist of a record signed by a physician, registered nurse practitioner, physician’s assistant, or his/her designee (the signature of the student's parents is not acceptable). This record may be submitted to the preschool or school by a health care provider, another preschool or school, a parent or a guardian.

   1. 1. An official immunization record card, preschool or school immunization record, Medical Passport, World Health Organization immunization record, or other official immunization records acceptable to the Department; or
   2. 2. An electronically stored and/or transmitted documentary record (facsimile transmission, computerized record, including, but not limited to, a record obtained from the KIDSNET statewide registry or other statewide registry, record on magnetic media or similar record) as may be utilized by a preschool or school; or
   3. 3. Presentation of laboratory evidence of immunity is made in the case of measles, mumps, rubella, hepatitis B and varicella (chickenpox); or,
   4. 4. For chickenpox (varicella), a physician, a physician assistant, a certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs a statement that the student has a history of chickenpox disease (varicella).

   5. 5. Telephone confirmation by the preschool or school or college of the existence of immunization records as defined above, provided all of the following conditions are met:

      1. a. An acceptable documentary record is on file with the preschool or school officials at a preschool or school which the student previously attended, or is on file with a health provider, public health agency, other health professional or preschool or school official responsible for maintenance of immunization records; and
      2. b. Telephone confirmation is obtained by a preschool or school official at the preschool or school in which the student enrolls; and
      3. c. Telephone confirmation is sought and obtained within one (1) working day of the student's initial entry; and
      4. d. Written documentation is made in the student's preschool or school health record of the telephone confirmation call, including the date and time of the call, the name, address, and telephone number of the person who confirmed the immunization status; and
      5. e. A written documentary record of immunization is received by the preschool or school in which the student has enrolled within ten (10) working days of initial entry; and

      6. f. The preschool or school shall implement the telephone confirmation as described above, if a student is seeking entry and does not present a copy of immunization records.

         3.5.4 Provisions for Exclusions, Waiting Periods and Exemptions

5. A. Exclusions

   1. 1. Students who have not received the minimum number of required immunizations, who are not in a prescribed waiting period between doses, as specified in § 3.5.4(B) of this Part and who are not exempt pursuant to § 3.5.4(C) of this Part, shall be excluded from the preschool or school by the administrative head of the preschool or school, pending the completion of the required dose(s) of vaccine(s).

   2. 2. Students upon initial entry to any preschool or school shall be excluded unless evidence is submitted that the student has received initial dose(s) of required vaccine(s) for preschool or school entry as set forth in these Regulations.

      1. a. The presence of a vaccine-preventable disease outbreak is determined in consultation with the Department. If an outbreak of vaccine-preventable disease should occur, an exempt student shall be excluded from school by the administrative head of school for a period of time as determined by the Department based on a case-by-case analysis of public health risk.
      2. b. The preschool or school shall have a written protocol in place for the exclusion of unvaccinated students in the event of an outbreak. An accurate and current listing of unvaccinated students shall be maintained by the preschool or school for this purpose.

6. B. Waiting Periods

   1. 1. If at initial preschool or school entry a student is within a waiting period for the minimum number of doses for a given vaccine, the student shall be registered and/or admitted to preschool or school. It shall be the responsibility of the administrative head of the preschool or school or his/her designee to ensure the completion of at least the minimum number of immunizations, following the prescribed waiting period(s) and consistent with the provisions of these Regulations.

      1. a. The administrative head of the preschool or school or his/her designee shall sign a Temporary Immunization Exemption Certificate, provided by the school, indicating that an appointment with a health care provider for the required immunization(s) has been made. This temporary exemption shall expire on the date of the immunization appointment.
   2. 2. At initial preschool or school entry a student who is under the care of the Department of Children, Youth and Families (DCYF) shall be enrolled in school upon presentation of a completed intra-state education identification card in accordance with the requirements of R.I. Gen. Laws § 42-72.4-1 or as stipulated in § 3.5.3 of this Part.

7. C. Exemptions

   1. 1. A student may only be exempt from the immunization requirements described in these Regulations for either of the two (2) reasons stated below:

      1. a. A physician, a physician assistant, a certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs the Rhode Island Department of Health’s “Medical Immunization Exemption Certificate” provided by the school attesting that the student is exempt from a specific vaccine because of medical reasons, in accordance with ACIP recommendations; or
      2. b. A parent or guardian completes and signs the Department’s “Religious Immunization Exemption Certificate” provided by the school, attesting that immunization conflicts with the tenets of their religious beliefs.

3.6 Minimum Standards for Immunization and Communicable Disease Testing for Students Entering Colleges or Universities

1. A. Each student, upon entering any college or university in Rhode Island, shall furnish evidence to the administrative head of the college or university (pursuant to the requirements of § 3.6.2 of this Part) that the student has been immunized, as required in § 3.6.1 of this Part, unless the student is in an exempt category (e.g., documented evidence of immunity).

2. B. For the immunization requirements stipulated in § 3.6.1 of this Part, a student who is not in compliance with these requirements shall be excluded from attending college or university classes until the requirements are met, unless the student belongs in an exemption category or is in a waiting period between doses as described in § 3.6.3(B) or § 3.6.3(C) of this Part.

   3.6.1 College or University Entry: Immunization Requirements

3. A. Each student, upon entering any college or university, shall furnish evidence as required in § 3.6.2 of this Part of having received the vaccines described below:

   1. 1. Tetanus, Diphtheria, Pertussis Vaccine. Evidence of having received a single dose of Tdap vaccine.
   2. 2. Measles, Mumps, and Rubella Vaccines. Two (2) doses of live measles, mumps and rubella vaccine given at least four (4) weeks apart beginning on or after twelve (12) months of age.
   3. 3. Hepatitis B Vaccine. Three (3) doses of hepatitis B vaccine administered in accordance with ACIP recommendations.
   4. 4. Varicella (Chickenpox) Vaccine. Two (2) doses of varicella vaccine given at least four (4) weeks apart beginning on or after twelve (12) months of age.

   5. 5. Meningococcal Vaccine. Beginning August 1, 2015, one (1) dose of meningococcal conjugate (MCV4) vaccine in the last 5 years is required for previously unvaccinated newly enrolled full-time undergraduate and graduate students (under twenty-two (22) years of age) in a degree program at a college or university who will live in a dormitory or comparable congregate living arrangement approved by the institution.

      3.6.2 Immunization Records

4. A. Acceptable evidence of completion of immunizations shall include the day, month, year and type/name of each dose of vaccine administered. The record of such evidence shall be signed by a physician, physician assistant, certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice (the signature of the student's parents is not acceptable). This record may be submitted to the college or university by a health care provider, another college or university, the student, or a parent/guardian.
5. B. For students who initially entered primary school on or before 31 December 1989, existing immunization records shall be deemed acceptable, provided the record contains a valid exemption form or contains documentation that the student has completed the required immunizations.

6. C. Acceptable evidence of completion of immunization consists of:

   1. 1. An official immunization record card, school immunization record, Medical Passport, World Health Organization immunization record, or other official immunization records acceptable to the Department; or
   2. 2. An electronically stored and/or transmitted documentary record (facsimile transmission, computerized record, including, but not limited to, a record on magnetic media or similar record) as may be utilized by a school; or
   3. 3. Presentation of laboratory evidence of immunity is made in the case of measles, mumps, rubella, hepatitis B, and varicella (chickenpox); or

   4. 4. A physician, physician assistant, certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs a statement that the student has a history of chickenpox disease (varicella).

      3.6.3 Provisions for Exclusions, Waiting Periods, and Exemptions

   5. A. Exclusions
   6. 1. Students who have not received the minimum number of required immunizations, who are not in a prescribed waiting period between doses, as specified in § 3.6.1 of this Part and who are not exempt pursuant to § 3.6.3(C) of this Part, shall be excluded from the college or university by the administrative head of the college or university, pending the completion of the required dose(s) of vaccine(s).
   7. 2. Students upon entering any college or university shall be excluded unless evidence is submitted that the student has received initial dose(s) of required vaccine(s) for college or university entry as set forth in these Regulations.
   8. 3. The presence of a vaccine-preventable disease outbreak is determined in consultation with the Department. If an outbreak of vaccine-preventable disease should occur, an exempt student shall be excluded from school by the administrative head of school for a period of time as determined by the Department based on a case-by-case analysis of public health risk.
   9. 4. The college or university shall have a written protocol in place for the exclusion of unvaccinated students in the event of an outbreak. An accurate and current listing of all unvaccinated students shall be maintained by the college or university for this purpose.

7. B. Waiting Periods

   1. 1. If, at college or university entry, a student is within a waiting period for the minimum number of doses for a given vaccine, the student shall be enrolled and/or admitted to the college or university. It shall be the responsibility of the administrative head of the college or university or his/her designee to ensure the completion of at least the minimum number of immunizations, following the prescribed waiting period(s) and consistent with the provisions of these Regulations.

8. C. Exemptions

   1. 1. A student may be exempt from the immunization requirements described in these Regulations provided that:

      1. a. A physician, physician assistant, certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs the Department’s “Medical Immunization Exemption Certificate” provided by the college/university attesting that the student is exempt from a specific vaccine because of medical reasons, in accordance with ACIP guidelines; or
      2. b. A parent or guardian or student (if eighteen) 18 years of age or older completes and signs the Department’s “Religious Immunization Exemption Certificate” provided by the college/university, attesting that immunization conflicts with the tenets of their religious beliefs; or
      3. c. The administrative head of the college or university or his/her designee signs a Temporary Immunization Exemption Certificate, provided by the college/university, indicating that an appointment with a health care provider for the required immunization(s) has been made. This temporary exemption shall expire on the date of the immunization appointment.

3.7 Tuberculosis Testing for Colleges/Universities

1. A. Targeted tuberculosis (TB) testing is required for entering students who are from highly endemic countries of the world and have been a resident in the United States for less than five (5) years. All other testing should be conducted according to the CDC Guidelines incorporated above at § 3.2(C) of this Part.

3.8 Minimum Standards for Immunization and Communicable Disease Testing for Child Care Workers in Preschools

1. A. Beginning August 1, 2015, in accordance with the National Health and Safety Performance Standards for Early Care and Education Programs incorporated above at § 3.2(D) of this Part, evidence of immunity is required for all child care workers (with the exception of child care workers who receive a medical exemption) against:

   1. 1. Tetanus, Diphtheria and Pertussis: one (1) dose of Tdap vaccine
   2. 2. Measles, Mumps and Rubella: two (2) doses of MMR vaccine
   3. 3. Chickenpox: two (2) doses of Varicella vaccine
   4. 4. Influenza: annual influenza vaccination, administered between July 1 and December 31 of each year, is required for all child care workers

   5. 5. Acceptable evidence of completion of immunization consists of:

      1. a. An official immunization record card, school immunization record, Medical Passport, World Health Organization immunization record, or other official immunization records acceptable to the Department; or
      2. b. An electronically stored and/or transmitted documentary record (facsimile transmission, computerized record, including, but not limited to, a record on magnetic media or similar record) as may be utilized by a school; or
      3. c. Presentation of laboratory evidence of immunity is made in the case of measles, mumps, rubella, hepatitis B, and varicella (chickenpox); or
      4. d. A physician, physician assistant, certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs a statement that the student has a history of chickenpox disease (varicella).

3.9 Reporting

1. A. The administrative head (or designee) of each preschool, school, college and university shall be responsible for reporting the immunization status of students and the number of students with a medical and/or religious exemption to the Department.
2. B. Such reporting shall occur according to procedures and format required by the Department.

3.10 Severability

1. A. If any provisions of these Regulations or the application thereof to any facility or circumstances shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.