“Application for Optometrists to Administer Immunizations

Per California Business and Professions Code §3041(g), you must have a current California Optometrist License and have a Therapeutic Pharmaceutical Agents (TPA) license type to be eligible for a certificate to administer immunizations. “Immunization” means the administration of immunizations for influenza, herpes zoster virus, pneumococcus, and

SARS-CoV-2, consistent with recommendations adopted pursuant to Section 120164 of the Health and Safety Code, for persons 18 years of age or older.

If eligible, you must also meet and maintain the following requirements for an immunization certificate:

1. Complete an immunization training program endorsed by the CDC or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and maintain that training.

2. Be certified in basic life support.

3. Comply with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering

information in the appropriate immunization registry designated by the immunization branch of the California State Department of Public Health.

To apply for an immunization certificate, provide documentation for items #1 and #2 above with your application. All documentation must be provided, or the application will be rejected.

First, Middle, and Last Name:_________________________

Email address:________________________________________

License No.:__________________________________________

1. I declare under penalty of perjury under the laws of the State of California that the information provided on this form and the attached documents or other requested proof of completion is true and accurate. I understand and agree that any misstatements of material facts may be cause for denial of the

Application for Optometrists to Administer Immunizations and disciplinary action by the California State Board of Optometry.

AND

2. I declare under penalty of perjury under the laws of the State of California that I will comply with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the California State Department of Public Health.

Optometrist Signature: _________________________________

Date:___________________________________________________”

by an application fee of fifty dollars ($50), or a fee in an amount as determined by the board, not to exceed the reasonable cost of administering this section.