Form CCL.305 "Immunization Report Form" - Kansas

What Is Form CCL.305?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.305 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.305 "Immunization Report Form" - Kansas

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Kansas Department of Health and Environment
CCL. 305
Bureau of Child Care and Health Facilities
Rev. 3/2017
Child Care Licensing Program
1000 SW Jackson Street, Suite 200
Topeka, KS 66612-1274
Phone: 785 296-1270 Fax: 785 559-4244
Website: www.kdheks.gov/kidsnet
Immunization Report Form
Check One:
Licensed Day Care Home
Group Day Care Home
Child Care Center
Preschool
Head Start
License Number:
Name of Facility (exactly as it appears on the license)
Address of Facility:
Street
City
Zip Code
County
Instructions: List the initials of children presently enrolled. Write the month, day, year (MM/DD/YYYY) of each immunization completed in each series in the boxes.
Initials
Date of Birth
Exemption?
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
(please check)
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
1
2
3
4
5
1
2
3
4
1
2
1
2
3
4
1
2
3
1
2
1
2
3
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1
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Kansas Department of Health and Environment
CCL. 305
Bureau of Child Care and Health Facilities
Rev. 3/2017
Child Care Licensing Program
1000 SW Jackson Street, Suite 200
Topeka, KS 66612-1274
Phone: 785 296-1270 Fax: 785 559-4244
Website: www.kdheks.gov/kidsnet
Immunization Report Form
Check One:
Licensed Day Care Home
Group Day Care Home
Child Care Center
Preschool
Head Start
License Number:
Name of Facility (exactly as it appears on the license)
Address of Facility:
Street
City
Zip Code
County
Instructions: List the initials of children presently enrolled. Write the month, day, year (MM/DD/YYYY) of each immunization completed in each series in the boxes.
Initials
Date of Birth
Exemption?
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
Medical
(please check)
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
Religious
1
2
3
4
5
1
2
3
4
1
2
1
2
3
4
1
2
3
1
2
1
2
3
4
1
2