Screening Checklist patient name

for Contraindications date of birth

month
/
day
/
year

to Vaccines for Children and Teens

For parents/guardians: The following questions will help us determine which vaccines your child may
be given today. If you answer “yes” to any question, it does not necessarily mean your child should not be
vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your
healthcare provider to explain it.
don’t
yes no know

1. Is the child sick today?

2. Does the child have allergies to medicine, food, a vaccine component, or latex?

3. Has the child had a serious reaction to a vaccine in the past?

4. Does the child have a long-term health problem with heart, lung (including asthma), kidney, liver, nervous
system, or metabolic disease (e.g., diabetes), a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak?
Are they taking regular aspirin or salicylate medication?

5. For children age 2 through 4 years: Has a healthcare provider told you that the child had
wheezing or asthma in the past 12 months?

6. For babies: Have you ever been told the child had intussusception?

7. Has the child, a sibling, or a parent had a seizure; has the child had a brain or other nervous system problem?

8. Has the child ever been diagnosed with a heart condition (myocarditis or pericarditis) or have they had
Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19?

9. Does the child have an immune-system problem such as cancer, leukemia, HIV/AIDS?

10. In the past 6 months, has the child taken medications that affect the immune system such as prednisone, other
steroids, or anticancer drugs; drugs to treat rheumatoid arthritis, Crohn’s disease, or psoriasis; or had radiation
treatments?

11. Does the child’s parent or sibling have an immune system problem?

12. In the past year, has the child received immune (gamma) globulin, blood/blood products, or an antiviral drug?

13. Is the child/teen pregnant?

14. Has the child received vaccinations in the past 4 weeks?

15. Has the child ever felt dizzy or faint before, during, or after a shot?

16. Is the child anxious about getting a shot today?

form completed by date

form reviewed by date

Did you bring your immunization record card with you? yes no
It is important to have a personal record of your child’s vaccinations. If you don’t have one, ask the child’s healthcare provider
to give you one with all your child’s vaccinations on it. Keep it in a safe place and bring it with you every time you seek medical
care for your child. Your child will need this document to enter day care or school, for employment, or for international travel.

www.immunize.org/catg.d/p4060.pdf
FOR PROFESSIONALS www.immunize.org / FOR THE PUBLIC www.vaccineinformation.org Item #P4060 (12/15/2023)
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Information for Healthcare Professionals about the Screening Checklist
for Contraindications to Vaccines (Children and Teens)
Read the information below for help interpreting answers to the screening checklist.
To learn even more, consult the references in Note below.
NOTE: For additional details, see CDC’s “Child and Adolescent Immunization following DTP/DTaP. An unstable progressive neurologic problem is a precaution to using
Schedule” (www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html) and DTaP and Tdap. A history of Guillain-Barré syndrome (GBS): a) Td/Tdap: GBS within
General Best Practice Guidelines for Immunization sections on “Contraindications and 6 weeks of a tetanus-toxoid vaccine is a precaution; if the decision is made to vaccinate,
Precautions” (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindica- give Tdap instead of Td; b) all influenza vaccines: GBS within 6 weeks of an influenza
tions.html) and “Altered Immunocompetence” (www.cdc.gov/vaccines/hcp/ vaccine is a precaution; influenza vaccination should generally be avoided unless the
acip-recs/general-recs/immunocompetence.html). For more details on COVID-19 benefits outweigh the risks (e.g., for those at higher risk for influenza complications).
vaccines, see “Use of COVID-19 Vaccines in the United States: Interim Clinical
Considerations” at www.cdc.gov/vaccines/covid-19/clinical-considerations/ 8. Has the child ever been diagnosed with a heart condition (myocarditis or pericarditis) or
covid-19-vaccines-us.html. have they had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus
that causes COVID-19?
1. Is the child sick today? [all vaccines] Precautions to COVID-19 vaccination include a history of myocarditis or pericarditis
There is no evidence that acute illness reduces vaccine effectiveness or safety. However, within 3 weeks after a dose of any COVID-19 vaccine or a history of Multisystem
as a precaution, all vaccines should be delayed until moderate or severe acute illness has Inflammatory Syndrome (MIS-C). Myocarditis or pericarditis within 3 weeks after a dose
improved. Mild illnesses with or without fever (e.g., otitis media, “colds,” and diarrhea) and of any COVID-19 vacine is a precaution: the person should generally not receive additional
antibiotic use are not contraindications to routine vaccination. COVID-19 vaccine. A child with a history of myocarditis or pericarditis unrelated to
vaccination may receive a COVID-19 vaccine once the condition has completely resolved.
2. Does the child have allergies to medicine, food, a vaccine component, or latex? [all vaccines] A child with a history of MIS-C may be vaccinated if the condition has fully resolved and it
Gelatin: If a person has anaphylaxis after eating gelatin, do not give vaccines containing has been at least 90 days since diagnosis. Refer to CDC COVID-19 vaccine guidance for
gelatin. Latex: An anaphylactic reaction to latex is a contraindication to vaccines with latex as additional considerations for myocarditis, pericarditis, and MIS (see Note).
part of the vaccine’s packaging (e.g., vial stoppers, prefilled syringe plungers, prefilled syringe
caps). For details on latex in vaccine packaging, refer to the package insert (listed at www.  9. Does the child have an immune-system problem, such as cancer, leukemia, HIV/AIDS?
fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states). COVID-19 [LAIV, MMR, MMRV, Rotavirus, VAR]
vaccine: History of a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to Live virus vaccines are usually contraindicated in immunocompromised people with exceptions.
a COVID-19 vaccine component is a contraindication to use of the same vaccine type. For example, MMR is recommended for asymptomatic HIV-infected patients who are not
People may receive the alternative COVID-19 vaccine type (either mRNA or protein severely immunosuppressed. VAR should be administered (if indicated) to people with isolated
subunit) if they have a contraindication or an allergy-related precaution to one COVID-19 humoral immunodeficiency. LAIV is contraindicated in immunosuppressed people; give IIV or RIV
vaccine type. Allergy-related precautions include history of 1) diagnosed non-severe instead. Infants with severe combined immunodeficiency (SCID) should not be given a live virus
allergy to a COVID-19 vaccine component; 2) non-severe, immediate (onset less than 4 vaccine, including rotavirus vaccine, but other forms of immunosuppression are a precaution, not
hours) allergic reaction after a dose of one COVID-19 vaccine type (see Note). a contraindication, to rotavirus vaccine. See “General Best Practice Guidelines: Altered Immuno-
Not contraindications: Eggs: ACIP and CDC do not consider egg allergy of any severity competence” at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html.
to be a contraindication or precaution to any egg-based influenza vaccine. Injection site
reaction (e.g., soreness, redness, delayed-type local-reaction) to a prior dose or vaccine 10. In the past 6 months, has the child taken medications that affect the immune system such as
component is not a contraindication to a subsequent dose or vaccine containing that prednisone, other steroids, or anticancer drugs; drugs to treat rheumatoid arthritis, Crohn’s
component. disease, or psoriasis; or had radiation treatments? [LAIV, MMR, MMRV, VAR]
Live virus vaccines should be postponed until after chemotherapy or long-term high-dose
3. Has the child had a serious reaction to a vaccine in the past? [all vaccines] steroid therapy has ended. See Note above. Some immune mediator and modulator drugs
• Anaphylaxis to a previous vaccine dose or vaccine component is a contraindication for (especially anti-necrosis factor [TNF] agents) may be immunosuppressive. Avoid live virus
subsequent doses of corresponding vaccines (see question 2). vaccines in people taking immunosuppressive drugs. A list of these is in CDC’s Yellow Book at
wwwwnc.cdc.gov/travel/yellowbook/2024/additional-considerations/immunocompromised-travelers.
• Usually, one defers vaccination when a precaution is present, unless the benefit
outweighs the risk (e.g., during an outbreak).
11. Does the child’s parent or sibling have an immune system problem? [MMR, MMRV, VAR]
• A history of encephalopathy within 7 days of DTP/DTaP is a contraindication for further
MMR, MMRV, and VAR vaccines should not be given to a patient with a family history of
doses of any pertussis-containing vaccine.
congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents, siblings)
• Other “serious reactions” that this child experienced following vaccination might unless the patient’s immune competence has been verified clinically or by a laboratory.
constitute contraindications or precautions to future doses. See the appendix on
vaccine contraindications and precautions in the Note section above. 12. In the past year, has the child received immune (gamma) globulin, blood/blood products, or
an antiviral drug? [MMR, MMRV, LAIV, VAR]
4. Does the child have a long-term health problem with heart, lung (including asthma), kidney,
See Note (schedule) for antiviral drug information (VAR, LAIV). See “Timing and Spacing of
liver, nervous system, or metabolic disease (e.g., diabetes), a blood disorder, no spleen, a
Immunobiologics” (www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html#antibody)
cochlear implant, or a spinal fluid leak? Are they taking regular aspirin or salicylate
for intervals between MMR, VAR, and certain blood/blood products, immune globulin.
medication? [MMR, MMRV, LAIV, VAR]
LAIV is not recommended for children with cerebrospinal fluid leak, anatomic or func- 13. Is the child/teen pregnant? [HPV, IPV, LAIV, MenB, MMR, MMRV, VAR]
tional asplenia, cochlear implant, a child age 2 through 4 years with a history of asthma or
wheezing, or current aspirin or salicylate-containing medication use. Precautions to LAIV Live virus vaccines (e.g., LAIV, MMR, MMRV, VAR) are contraindicated in pregnancy due to
include any underlying health condition that increases the risk of influenza complications the theoretical risk of virus transmission to the fetus. People who could become pregnant
(see package insert or CDC schedule for details). MMR & MMRV: A history of thrombocy- and receive a live virus vaccine should be instructed to avoid pregnancy for 1 month after
topenia or thrombocytopenic purpura is a precaution to MMR and MMRV. VAR: Aspirin vaccination. IPV and MenB should not be given except to those with an elevated risk of
use is a precaution to VAR due to the association of aspirin use, chickenpox, and Reye exposure during pregnancy. HepB: Heplisav-B and PreHevbrio are not recommended during
syndrome in children and adolescents. pregnancy, use Engerix-B or Recombivax-HB. HPV is not recommended during pregnancy.

5. For children age 2 through 4 years: Has a healthcare provider told you that the child had 14. Has the child received vaccinations in the past 4 weeks? [LAIV, MMR, MMRV, VAR,
wheezing or asthma in the past 12 months? [LAIV] yellow fever]
Children ages 2 through 4 years who had a wheezing episode within the past 12 months Children given live virus vaccines, such as those listed above, should wait 28 days before
should not get LAIV. Give IIV or RIV instead. receiving another live virus vaccine (wait 30 days for yellow fever vaccine). Inactivated
vaccines may be given at the same time or at any spacing interval.
6. For babies: Have you ever been told the child had intussusception? [Rotavirus]
Infants who have a history of intussusception (i.e., the telescoping of one portion of the 15. Has the child ever felt dizzy or faint before, during or after a shot?
intestine into another) should not be given rotavirus vaccine. Fainting (syncope) or dizziness is not a contraindication or precaution to vaccination;
it may be an anxiety-related response to any injection. CDC recommends vaccine
7. Has the child, a sibling, or a parent had a seizure; has the child had a brain or other nervous providers consider observing all patients for 15 minutes after vaccination. See Immunize.
system problem? [DTaP, Td, Tdap, IIV, LAIV, MMRV, RIV] org’s resource on vaccination and syncope at www.immunize.org/catg.d/p4260.pdf.
For patients with stable neurologic disorders (including seizures) unrelated to vaccination,
or with a family history of seizures, vaccinate as usual (exception: children with a first 16. Is the child anxious about getting a shot today?
degree relative [e.g., parent or sibling] or personal history of seizures generally should Anxiety can lead to vaccine avoidance. Simple steps can ease a patient’s anxiety about
receive separate MMR and VAR, not MMRV). Pertussis-containing vaccines: DTaP and vaccination. Visit Immunize.org’s “Addressing Vaccination Anxiety” clinical resources at
Tdap are contraindicated in children who have a history of encephalopathy within 7 days www.immunize.org/clinical/topic/addressing-anxiety/
vaccine abbreviations
DTaP = Diphtheria, tetanus, & acellular pertussis vaccine IPV = Inactivated poliovirus vaccine MMRV = MMR+VAR vaccine
HPV = Human papillomavirus vaccine LAIV = Live attenuated influenza vaccine RIV = Recombinant influenza vaccine
IIV = Inactivated influenza vaccine MenB = Meningococcal B vaccine Td, Tdap = Tetanus, diphtheria, (acellular pertussis) vaccine
ccIIV - cell culture inactivated influenza vaccine MMR = Measles, mumps, and rubella vaccine VAR = Varicella vaccine

www.immunize.org/catg.d/p4060.pdf / Item #P4060 (12/15/2023)