MARYLAND DEPARTMENT OF HEALTH IMMUNIZATION CERTIFICATE - MDH Form 896

Sep 4, 2026

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Maryland Department of Health immunization certificate form used to record a student’s or self’s immunization history, including vaccine names and dose dates across childhood and recommended series. The form collects identifying details and school information, provides signature sections for medical providers, and includes guidance for how to complete and certify immunization entries, including rules for transcription from authenticated records. It also contains exemption sections for medical contraindications and religious objections, plus notes and referenced Maryland school immunization requirements.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Student / Self Information

Immunization Record Table (Doses and Dates)

Certification Signatures

Provider / Official Signatures

Exemption Sections

Medical Contraindication

Religious Objection

How To Use This Form

Recording Dates and Certification

Transcription From Other Authenticated Records

Notes and Immunization Requirements

MARYLAND DEPARTMENT OF HEALTH IMMUNIZATION CERTIFICATE | STUDENT/SELF NAME:
LAST FIRST MI
STUDENT/SELF ADDRESS: CITY: ZIP:
SEX: MALE □ FEMALE □ OTHER □ BIRTH DATE: / /
COUNTY: SCHOOL: GRADE: | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | FOR MINORS UNDER 18:
PARENT/GUARDIAN NAME: PHONE \#: | | | | | | | | | | | | | | | | \# | DTP-DTaP
DT
Mo/Day/Yr | Polio
Mo/Day
/Yr | Hib
Mo/Da
y/Yr | Hep B
Mo/Day/Yr | PCV
Mo/Day/Yr | Rotavirus
Mo/Day/Yr | MCV
Mo/Day/Yr | HPV
Mo/Day/Yr | Hep A
Mo/Day/Yr | MMR
Mo/Day/Yr | Varicella
Mo/Day/Yr | Varicella
Disease
Mo / Yr | COVID-19
Mo/Day/Yr | | | 1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#6 | | 2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | | DOSE
\#2 | DOSE
\#7 | | 3 | DOSE
\#3 | DOSE
\#3 | DOSE
\#3 | DOSE
\#3 | DOSE
\#3 | DOSE
\#3 | DOSE
\#3 | DOSE
\#3 | Td
Mo/Day/Yr | Tdap
Mo/Day/Yr | MenB
Mo/Day/Yr | Other
Mo/Day/Yr | DOSE
\#3 | DOSE
\#8 | | 4 | DOSE
\#4 | DOSE
\#4 | DOSE
\#4 | DOSE
\#4 | DOSE
\#4 | | | | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#1 | DOSE
\#4 | DOSE
\#9 | | 5 | DOSE
\#5 | | | DOSE
\#5 | | | | | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#2 | DOSE
\#5 | DOSE
\#10 | | | | | | | | | | | DOSE
\#3 | | DOSE
\#3 | | | | | To the best of my knowledge, the vaccines listed above were administered according to the provided information in Maryland’s Immunization Information System.
1.
Signature Title Date
(Medical provider, local/state health department official, school official, or child care provider only)
2. Signature Title Date
3. Signature Title Date
Signature lines 2 and 3 are for certification of vaccines given after the initial signature. Otherwise, this form may not be altered. | | | | | | | | | | Clinic / Office Name
Office Address/ Phone Number
| | | | | COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE. MEDICAL CONTRAINDICATION: Please check the appropriate box to describe the medical contraindication. This is a: □ Permanent condition OR □ Temporary condition until / / Date The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the contraindication, Signed: Date: Medical Provider / LHD Official RELIGIOUS OBJECTION: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child. This exemption does not apply during an emergency or epidemic of disease. Signed: Date: MDH Form 896 (Formally DHMH 896) Center for Immunization [Rev. 06/25 www.health.maryland.gov/Imm](Rev. 06/25 www.health.maryland.gov/Imm) How To Use This Form The medical provider that gave the vaccinations may record the dates (using month/day/year) directly on this form (check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, by each component of the vaccine. A different medical provider, local health department official, school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record which has the authentication of a medical provider, health department, school, or child care service. Only a medical provider, lo

FAQs

What information is collected on the Maryland immunization certificate form?

The form collects student/self name and address, sex, birth date, county, school, and grade, along with parent/guardian details when the student is under 18.

Who is allowed to sign the “Record of Immunization” section?

Only a medical provider, local health department official, school official, or child care provider may sign the immunization record certification section.

How do medical and religious exemptions work on this form?

The form provides sections to document medical contraindications (permanent or temporary, with the vaccine(s) and reason) and a separate religious objection statement signed by the parent/guardian. The religious exemption does not apply during a disease emergency or epidemic.

Sep 4, 2026

Upload by Gloria