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Provisional Certificate of Immunization (West Virginia)

This report creates a Provisional Certificate of Immunization for a specific patient. Search for the patient first.

This yellow certificate includes an option for a temporary medical exemption. If this option is enabled (selected), Part B of the form is populated and both sides are printed. A Yes appears in the History of Varicella section if parent report of disease is recorded. If this option is disabled (deselected), Part A is populated and both sides print.

To create this Provisional Certificate of Immunization, search for the patient and then click the Reports > State Reports > Provisional Certificate of Immunization > Current Patient's Form link. The Provisional Certificate of Immunization page opens. Select the Temporary Medical Exemption option if necessary and click Continue. The West Virginia Provisional Certificate of Immunization opens in a new window.