Reports due October 15, 2014 Oc October 15, 2013 HOW TO COMPLETE THE ONLINE CHILD CARE IMMUNIZATION ASSESSMENT STEP 1: Download/Access the Child Care Worksheet and the Child Care Immunization Requirements The Child Care Worksheet (CDPH 8342), the California Immunizations Required for Child Care, and a blank blue California School Immunization Record (CSIR) or Blue Card are in your packet or can be downloaded at: www.shotsforschool.org/reporting. Some facilities have electronic systems and may not need the worksheet. STEP 2: Determine Each Student’s Number of Doses Received for Each Vaccine Type and Enter into the Worksheet: POLIO DOSES DTP/Td DOSES MMR1 HIB 1 EXEMPT VARICELLA2 HEP B T yp e o f p er so nal b elief s exemp t io n NAME/I.D. DOB 1. Tracy 2. Darren 3. Jed 4. Amber 5. Sandra GRAND TOTAL 05/24/12 09/18/12 02/18/12 12/31/11 12/20/11 CDP H 8018 SUM M A RY REP ORT FIELDS Followup Needed 0 √ √ 1 2 3+ 0 1 2 3 4+ 0 1+ 0 1+ 0 √ √ √ √ 1 3a. √ 2 0 1 2 √ 1 0 0 1 √ √ √ √ √ √ √ 3 3 √ √ √ √ √ 2 √ 1 4 1 2 3+ 0 √ √ 1+ med3 pers4 1 5 P ra c t. 6 Relig iou s 7 √ √ √ √ 0 2014 √ √ √ 1 p re- Jan He a lth Ca re 3 P OLIO0 P OLIO1 P OLIO2 P OLIO3 DTP 0 DTP 1 DTP 2 DTP 3 DTP 4 M M R0 M M R1 HIB 0 HIB 1 HEP B 0 HEP B 1 HEP B 2 HEP B 3 √ √ √ √ 3 2 1 √ 2 0 1 √ 1 VA RI0 VA RI1 2a. 2b. 2b (i) 2b (ii) 2b (iii) *Note: Although Tracy, above, has BOTH a pre-Jan 2014 and a Health Care Practitioner personal beliefs exemption, count ONLY the latest exemption; count ONLY the Health Care Practitioner exemption. 1. Enter name, initials, or I.D. for each child. Enter the date of birth for each child 2-4yrs 11 months. For each child, check ONE and ONLY ONE box under each vaccine type (POLIO, DTP/Td, MMR, HIB, HEP B, VARICELLA), indicating the total number of doses of that vaccine the child has received. (i.e, if a child received a total of 3 doses of Polio vaccine, check the POLIO (3) column.) If a child has not received the vaccine, check the zero (0) column. 2. Check only the last dose of polio vaccine received. If a child has not received the vaccine, check the zero (0) column. 3. Check only the last dose of DTP/DTaP vaccine received. If a child has not received the vaccine, check the zero (0) column. rev 09/14 4. For measles, mumps and rubella, check the MMR (1+) column only if the vaccine was given on or after the first birthday. If a child has not received the vaccine, check the zero (0) column. 5. For Hib, check the HIB (1+) column only if the vaccine was given on or after the first birthday. If a child has not received the vaccine, check the zero (0) column. 6. Check only the last dose of hepatitis B vaccine received. If a child has not received the vaccine, check the zero (0) column. 7. Check the varicella (1+) column only if the child has received the vaccine or has physician-documented varicella (chickenpox) disease. If the child has not received the vaccine and does not have physician documentation of the disease, check the zero (0) column. 8. Check the medical exemption column (med) only if the parent has provided a written statement from a licensed physician. 9. Check the personal beliefs exemption column (pers) only if the parent has: For entry before January 1, 2014: signed a statement of personal beliefs on the back of CA School Immunization Record OR For entry after January 1, 2014: completed the ‘new’ PBE Form ( ‘Personal Beliefs Exemption to Required Immunizations’ -CDPH 8262) AND check only one of the following: Pre-January 2014 column - if the child only has personal beliefs exemption(s) prior to January 1, 2014 OR Health Care Practitioner column - if there is documentation of counseling from an authorized health care practitioner in section A of CDPH 8262 or its equivalent* OR Religious column - if the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262* *Note: If, both pre-January 2014 and a new PBE Form are submitted, only indicate the PBE type recorded on the new PBE Form). 10. Check the follow-up needed column only if the child: has less than 3 polio, 4 DTP/DTaP, 1 each of measles, mumps and rubella (MMR) on or after the first birthday, 1 hib on or after the first birthday, 3 hepatitis B, 1 varicella or physician documented varicella (chickenpox) disease), AND does not have a permanent medical exemption to immunization or a personal beliefs exemption. 11. After all children have been listed and the immunization information in each row has been entered, count the number of check marks in each column and enter the total at the bottom of the worksheet. When applicable, please use the subtotal row for centers with an enrollment of more than 20 children. For example, if Tracy, the first student listed in the table in Step 2 above, has received a total of: 2 doses of Polio, check the POLIO (2) column in Tracy’s row as shown above. 3 doses of DTaP, check the the DTP/Td (3) column st 1 dose each of MMR and HIB after her 1 birthday, check the MMR (1+) and HIB (1+) column 3 doses of Hepatitis B, check the HEP B (3) column 0 doses of Varicella, check the VARICELLA (0) column 2 personal beliefs exemptions: 1 pre-Jan 2014 exemption and 1 Health Care Practitioner Counseled exemption; under ‘EXEMPT’, check ‘Pers’ and under ‘Type of Personal Beliefs Exemption’ check ONLY Health Care Pract. Counseled. rev 09/14 STEP 3: Login to the Child Care Reporting Site: a. Go to www.shotsforschool.org b. Click on the Child Care/School Reporting tab on the left side of the main page. c. Click on the Child Care/Preschool link to open the Child Care Reporting page. STEP 4: Completing & Submitting Your Report Online: Reports due October 15, 2014 rev 09/14 a. Login: Choose from the drop down menus your Facility’s: County, City, Facility Name, and Facility Address. Then enter the Password: allshots and click the Log in button. Reports due October 15, 2014 b. Update Facility Information: If necessary, update your facility’s address or name by selecting Edit Facility Info to make corrections. Then select Update. Then select Confirm and continue. NOTE: To ensure you receive future immunization assessment reporting communication, please update your contact information with Dept. of Social Services, Community Care Licensing if you’ve not done so this year. Reports due October 15, 2014 rev 09/14 c. Confirm Facility Status: If your facility does not have children enrolled this year, select Inactive or Closed for Facility Status . If your facility only has children enrolled over 5 years, select Over 5 only. If your facility only has children enrolled under 2 year, select Under 2 only. Then, skip to step e below. If your facility does have children enrolled this year, select Active. Answer the questions pertaining to enrollment under 2 years of age. Select an answer for the question: Are any children that you care for between 2 years to 4 years-11 months? d. Completing the Report Enter the number of enrolled children under 2 years of age. And indicate you have checked the immunization status of these children. Enter the number of children ages 2 years to 4 years11 months. Transfer the total numbers from the bottom of the worksheet columns to the corresponding boxes on the vaccine dose summary section of the report. Please note: the boxes in each row must add up to the total enrollment of children ages 2 years to 4 years-11 months (i.e., if one exempt child received 0 doses of polio, put a 1 in the polio 0 box). Transfer the total number of medical and personal beliefs exemptions to the corresponding lines on the exemptions section of the report. NOTE: Row 2b will auto sum based on 2bi +2bii +2biii. Transfer the total number of children who have Followup Needed to the corresponding box in the follow-up section of the report. NOTE: Put children with permanent medical exemptions or personal beliefs exemptions in the No Follow-up Needed box. Subtract this number from the TOTAL ENROLLMENT ages 2 to 4 years-11 months number and enter the result in the box No Follow-up Needed. Double check that the two boxes summing the Number of Children with Follow-up Needed plus Number of Children with No Follow-up Needed is equal to the TOTAL ENROLLMENT ages 2 to 4 years 11 months. rev 09/14 e. Submitting Your Report: Include your contact information as the report submitter and an additional designated facility contact. Review your information for accuracy and then select Submit to submit your report. Make sure you see the confirmation on the next screen that the report was successfully submitted. Print/Save a copy for your records by selecting Print or Download PDF. Retain your worksheet for your records. All reports must be submitted on or before October 15th or earlier if instructed by your local health department. If you will be reporting for another facility, select Logout to return to the login page and repeat steps 1-4. Congratulations, you have completed the report online! Questions? If you have any question, contact your local health department. rev 09/14 Frequently Asked Questions (FAQs) Child Care Immunization Assessment 1. Q: What is my password? A: Your password is: allshots 2. Q: What if I cannot find my facility in the drop down box? A: If your newly licensed facility is not listed, you will not be required to report this year, but will next year once your facility is added to the master DSS or CDE lists. 3. Q: Where do I order blue California School Immunization Records (CSIRs)? A: Contact your local health department at the number listed on the next page to order blue CSIRs or obtain a copy online. 4. Q: I do not have internet access, how do I submit my report? A: If you need a paper version of the report form, contact your local health department at the phone number listed on the next page. 5. Q: I cannot access the web address. What should I do? A: If your internet browser has internet capability to other sites, but you receive site error messages when trying to access www.shotsforschool.org, please contact [email protected]. 6. Q: I do not have a PDF reader. Where can I get one? A: You can download free software at either http://get.adobe.com/reader/ or http://www.foxitsoftware.com/. 7. Q: If I submit my report online, do I need to mail the paper form to the Local Health Dept? A: No. If you submit your report online, you do not need to mail the paper form to your local health department. However, please remember to follow up with children who need their shots and print out a paper copy of the report for your records. HELP If you need further assistance, please contact your local health department at the number listed on the memo or on the next page. Rev. 08/14 Local Health Department Phone Numbers Do you need more California School Immunization Records (Blue CSIR Cards) or have any questions? Contact your local health department at the number listed below. County (Website Link) Phone County (Website Link) Phone County (Website Link) Phone Alameda 510-267-3230 Madera 559-675-7893 San Luis Obispo 805-781-5500 Alpine 530-694-2146 Marin 415-473-3078 San Mateo 650-573-2877 Amador 209-223-6407 Mariposa 209-966-3689 Santa Barbara 805-346-8420 Berkeley City 510-981-5300 Mendocino 707-472-2600 Santa Clara 408-937-2271 Butte 530-538-7581 Merced 209-381-1023 Santa Cruz 831-454-4645 Calaveras 209-754-6460 Modoc 530-233-6311 Shasta 800-971-1999 Colusa 530-458-0380 Mono 760-924-1830 Sierra 530-993-6705 Contra Costa 925-313-6767 Monterey 831-755-4683 Siskiyou 530-841-2134 Del Norte 707-464-3191 Napa 707-253-4270 Solano 707-784-8001 El Dorado 530-621-6100 Nevada 530-265-1450 Sonoma 707-565-4567 Fresno 559-600-3550 Orange 714-834-8560 Stanislaus 209-558-4817 Glenn 530-934-6588 Pasadena City 626-744-6000 Sutter 530-822-7215 Humboldt 707- 268-2108 Placer 530-889-7141 Tehama 530-527-6824 Imperial 760-482-4438 Plumas 530-283-6330 Trinity 530-623-8218 Inyo 760-873-7868 Riverside 951-358-7125 Tulare 800-834-7121 Kern 661-321-3000 Sacramento 916-875-7468 Tuolumne 209-533-7401 Kings 559-852-2579 San Benito 831-637-5367 Ventura 805-981-5211 Lake 707-263-1090 San Bernardino 800-722-4794 Yolo 530-666-8645 Lassen 530-251-8183 San Diego 866-358-2966 Yuba 530-749-6366 Long Beach City 562-570-4315 San Francisco 415-554-2830 Los Angeles 213-351-7800 San Joaquin 209-468-3481 Rev 07/14 State of California-Health and Human Services Agency California Department of Public Health Worksheet for the Annual Immunization Report On Children Enrolled in Child Care Centers (Side 1) Only list ALL children ages 2 through 4 years, 11 months Check the box indicating the total number of doses received for each vaccine Page_______ of________ VACCINE DOSE SUMMARY POLIO DOSES NAME OR I.D. OF CHILD Example: Sierra DOB FollowUp Needed 0 1 2 3+ 0 1 2 3 4+ 0 √ √ 4/14/2012 MMR1 DTP/Td DOSES 1+ HIB1 0 √ 1+ √ VARICELLA2 HEP B 0 1 2 3+ 0 √ √ EXEMPT Type of personal beliefs exemption 1+ med3 pers4 Pre-Jan 20145 √ Health Care Pract. 6 Counseled Religious Exemption7 √ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SUBTOTAL (If Applicable) GRAND TOTAL CDPH 8018 SUMMARY REPORT FIELDS 1 3a. POLIO0 POLIO1 POLIO2 POLIO3 DTP0 DTP1 DTP2 DTP3 DTP4 MMR0 MMR1 HIB0 HIB1 HEPB0 HEPB1 HEPB2 HEPB3 Count as 1+ only if vaccine given on or after the first birthday. 2 One dose of varicella vaccine or physician-documented varicella (chickenpox) disease is required by law for children ages 18 months and older effective 7/1/01. If a child has received the vaccine or has physician-documented varicella (chickenpox) disease, check the varicella 1+ column. VARI0 VARI1 2a. 2b. 2b (i) 2b (ii) 2b (iii) (over) 3 Medical exemption to some or all immunizations Personal beliefs exemption to some or all immunizations 5 Personal beliefs exemption to some or all immunizations taken before January 1, 2014 (i.e., parent or guardian signed affidavit on back of blue California School Immunization Record); check this column if the child only has personal beliefs exemption(s) prior to January 1, 2014 4 6 Health Care Practitioner Counseled personal beliefs exemption to some or all immunizations taken on or after January 1, 2014; if there is documentation of counseling from an authorized health care practitioner in section A of CDPH 8262 or its equivalent. *Only check this column, and don’t check the pre-January 2014 column, when parents have submitted multiple valid exemptions that included this category along with pre-January 2014 personal belief Religious personal beliefs exemption to some or all immunizations taken on or after January 1, 2014; if the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262. Only check this column, and don’t check the pre-January 2014 column, when parents have submitted multiple valid exemptions that included this category along with pre-January 2014 personal belief exemption(s). CDPH 8342 (Rev 7/2014) 7 State of California-Health and Human Services Agency Worksheet for the Annual Immunization Report On Children Enrolled in Child Care Centers (Side 2) Only list ALL children ages 2 through 4 years, 11 months Check the box indicating the total number of doses received for each vaccine Page_______ of________ VACCINE DOSE SUMMARY POLIO DOSES NAME OR I.D. OF CHILD DOB FollowUp Needed 0 1 2 3+ DTP/Td DOSES 0 1 2 3 MMR 4+ 0 1 1+ 1 HEP B HIB 0 1+ 0 1 2 VARICELLA 3+ 0 2 EXEMPT 1+ med3 pers4 Type of personal beliefs exemption Pre-Jan 5 2014 Health Care Pract. 6 Counseled Religious 7 Exemption 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 SUBTOTAL 1 Count as 1+ only if vaccine given on or after the first birthday. 2 One dose of varicella vaccine or physician-documented varicella (chickenpox) disease is required by law for children ages 18 months and older effective 7/1/01. (over) If a child has received the vaccine or has physician-documented varicella (chickenpox) disease, check the varicella 1+ column. 3 Medical exemption to some or all immunizations 4 Personal beliefs exemption to some or all immunizations 5 Personal beliefs exemption to some or all immunizations taken before January 1, 2014 (i.e., parent or guardian signed affidavit on back of blue California School Immunization Record); check this column if the child only has personal beliefs exemption(s) prior to January 1, 2014 6 Health Care Practitioner Counseled personal beliefs exemption to some or all immunizations taken on or after January 1, 2014; if there is documentation of counseling from an authorized health care practitioner in section A of CDPH 8262 or its equivalent. *Only check this column, and don’t check the pre-January 2014 column, when parents have submitted multiple valid exemptions that included this category along with pre-January 2014 personal belief 7 Religious personal beliefs exemption to some or all immunizations taken on or after January 1, 2014; if the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262. Only check this column, and don’t check the pre-January 2014 column, when parents have submitted multiple valid exemptions that included this category along with pre-January 2014 personal belief exemption(s). CDPH 8342 (Rev 7/2014) CALIFORNIA IMMUNIZATION REQUIREMENTS FOR Child Care REFERENCE Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075 INSTRUCTIONS To attend child care, children must have immunizations outlined below by age. Parents must present their child's Immunization Record as proof of immunization. Copy the full date of each shot onto the blue California School Immunization Record card and then determine if the child is up-to-date. Blue cards are available free from the Immunization Coordinator at your local health department. As the child care provider, it is your responsibility to follow up regularly until all shots are finished. IMMUNIZATIONS (SHOTS) REQUIRED TO ATTEND CHILD CARE, BY AGE Age When Entering Immunizations (Shots) Required 2–3 months ....................1 each of Polio, DTaP, Hib, Hep B 4–5 months.................... 2 each of Polio, DTaP, Hib, Hep B 6–14 months.................. 3 DTaP 2 each of Polio, Hib, Hep B 15–17 months................ 3 each of Polio, DTaP 2 Hep B 1 MMR, on or after the first birthday1 1 Hib, on or after the first birthday1, 3 18 months–5 years......... 3 Polio 4 DTaP 3 Hep B 1 MMR, on or after the first birthday1 1 Hib, on or after the first birthday1, 3 1 Varicella (chickenpox)2 Vaccines DTaP : Diphtheria, tetanus, and pertussis combined vaccine. Hib: Haemophilus influenzae type b vaccine; required only for children up to age 4 years, 6 months. MMR: Measles, mumps, and rubella combined vaccine. Hep B: Hepatitis B vaccine. Varicella: Chickenpox vaccine. You may admit a child who is lacking one or more required vaccine doses if the dose(s) is not currently due on the condition that they receive the remaining dose(s) when due, according to the schedule above. You will need to review records to make sure this occurs. If the maximum time interval between doses has passed, the child cannot be admitted until the next immunization is obtained. WHEN NEXT SHOTS ARE DUE 1 Receipt of the dose up to (and including) 4 days before the birthday will satisfy the child care entry immunization requirement. 2 If a child had chickenpox disease and this is indicated on the Immunization Record by the child's physician, they meet the requirement. Write "disease" in the chickenpox date box on the blue card. 3 Required only for children who have not reached the age of 4 years 6 months. Polio #2......................... 6–10 weeks after 1st dose Polio #3......................... 6 weeks–12 months after 2nd dose DTaP #2, #3................... 4–8 weeks after previous dose Hib #2 ........................... 2–3 months after 1st dose DTaP #4 ......................... 6–12 months after 3rd dose Hep B #2........................1–2 months after 1st dose Hep B #3........................Under age 18 months: 2–12 months after 2nd dose and at least 4 months after 1st dose Age 18 months and older: 2–6 months after 2nd dose and at least 4 months after 1st dose EXEMPTIONS The law allows parents/guardians to submit an exemption from immunization requirements based on their personal beliefs or medical conditions. For children with medical exemptions, the physician’s written statement should be submitted. Child care staff should maintain an up-to-date list of pupils with exemptions, so they can be excluded quickly if an outbreak occurs. For more information, visit ShotsForSchool.org IMM-230 (8/14) California Department of Public Health • Immunization Branch • ShotsForSchool.org REQUISITOS DE INMUNIZACIÓN DE CALIFORNIA PARA EL Cuidado infantil REFERENCIA Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075 INSTRUCCIONES Para asistir al cuidado infantil, los niños deben vacunarse como anotado abajo, de acuerdo a su edad. Los padres deben presentar el Comprobante de Vacunación de su hijo antes de inscribirlo. Anote la fecha completa de cada vacuna en el Comprobante de Vacunación Escolar de California (la tarjeta azul). De esa manera, puede determinar si el niño está al día. Las tarjetas azules se pueden solicitar sin costo alguno al Coordinador de Vacunación de su departamento de salud local. Como proveedor de cuidado infantil, es su responsabilidad dar seguimiento con regularidad hasta que los niños hayan recibido todas sus vacunas. VACUNAS REQUERIDAS PARA ASISTIR A LA GUARDERIA, POR EDAD Edad al entrar Vacunas requeridas 2 a 3 meses ....................1 de cada una de las siguientes: poliomielitis, DTaP, Hib, Hep B 4 a 5 meses ....................2 de cada una de las siguientes: poliomielitis, DTaP, Hib, Hep B 6 a 14 meses ..................3 DTaP 2 de cada una de las siguientes: poliomielitis, Hib, Hep B 15 a 17 meses ................3 de cada una de las siguientes: poliomielitis, DTaP 2 Hep B 1 MMR en la fecha en que cumple un año de edad o después1 1 Hib en la fecha en que cumple un año de edad o después1, 3 18 meses a 5 años .......... 3 poliomielitis 4 DTaP 3 Hep B 1 MMR en la fecha en que cumple un año de edad, o después1 1 Hib en la fecha en que cumple un año de edad, o después1, 3 1 varicela Vacunas DTaP: Vacuna combinada contra la difteria, el tétanos y la tos ferina. Hib: Vacuna contra la Haemophilus influenzae tipo b; requerida sólo para los niños de hasta 4 años y medio (4 años, 6 meses). MMR: Vacuna combinada contra el sarampión, las paperas y la rubéola. Hep B: Hepatitis B. Varicela: Vacuna contra la varicela. Puede admitir a un niño aunque le falten una o más dosis de las vacunas requeridas, si es que las dosis aún no le corresponden, con la condición de que reciba la(s) dosis restantes cuando se las tenga que aplicar, de acuerdo al calendario de vacunas arriba. Usted tendrá que dar seguimiento para verificar que el niño se vacunó. Si transcurrió el intervalo de tiempo máximo entre las dosis, no se puede admitir al niño hasta que reciba la próxima vacuna. Comprobante de la dosis hasta 4 días antes del cumpleaños satisface el requisito para entrar a la guardería. Si un niño tuvo varicela y el doctor lo documentó en su Comprobante de Vacunación, se ha cumplido el requisito. Escriba "enfermedad" en el espacio de varicela en la tarjeta azul en donde generalmente se escribe la fecha. 3 Requerida sólo para niños menores de 4 años y medio (4 años, 6 meses). 1 2 CUANDO DEBE RECIBIR LAS PROXIMAS VACUNAS Poliomielitis No. 2................ entre 6 y 10 semanas después de la primera dosis Poliomielitis No. 3................ entre 6 semanas y 12 meses después de la segunda dosis DTaP No. 2, No. 3................ entre 4 y 8 semanas después de la dosis anterior Hib No. 2............................. entre 2 y 3 meses después de la primera dosis DTaP No. 4........................... entre 6 y 12 meses después de la tercera dosis Hep B No. 2......................... entre 1 y 2 meses después de la primera dosis Hep B No. 3......................... Para los niños menores de 18 meses de edad: entre 2 y 12 meses después de la segunda dosis y al menos 4 meses después de la primera dosis Para los niños mayores de 18 meses de edad: entre 2 y 6 meses después de la segunda dosis y al menos 4 meses después de la primera dosis EXENCIONES La ley permite que los padres o tutores opten por eximir a sus hijos de los requisitos de vacunación debido a sus creencias personales o por motivos médicos. Para los niños con exenciones médicas, la declaración escrita del doctor deber ser presentada. El personal de la guardería debe mantener una lista actualizada de los niños con exenciones para que en el caso de un brote, esos niños puedan ser excluidos de la guardería. El personal de la guardería rápidamente. Para más información, visite ShotsForSchool.org State of California • Department of Public Health • Immunization Branch • 850 Marina Bay Pkwy. • Richmond, CA 94804 • 510-620-3737 IMM-230S (8/14) CALIFORNIA SCHOOL IMMUNIZATION RECORD This record is part of the student's permanent record (cumulative folder) as defined in Section 49068 of the Education Code and shall transfer with that record. Local health departments shall have access to this record in schools, child care facilities, and family day care homes. This record must be completed by school and child care personnel from an immunization record provided by parent or guardian. See reverse side for instructions. Student Name Sex: M F Birthdate Place of Birth Race/Ethnicity: Name of Parent or Guardian Address White, not Hispanic Hispanic Black Telephone Daytime City Other: Nighttime DATE EACH DOSE WAS GIVEN VACCINE POLIO (OPV or IPV) (Diphtheria, tetanus and [acellular] pertussis OR tetanus and diphtheria only) 2nd 3rd 4th 5th / / / / / / / / / / / / / / / / MMR (Measles, mumps, and rubella) / / / / HIB (Required only for child care and preschool) / / / / / / / / HEPATITIS B / / / / / / VARICELLA (Chickenpox) / / / / HEPATITIS A (Not required) / / / / TB SKIN TESTS Type* Date given Date read mm indur Impression PPD-Mantoux Other / / / / Pos Neg PPD-Mantoux Other / / / / Pos Neg *If required for school entry, must be Mantoux unless exception granted by local health department. STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH IMMUNIZATION BRANCH I. DOCUMENTATION 1st / / DTP/DTaP/DT/Td ZIP Booster / / CHEST X-RAY (Necessary if skin test positive) Film date: / / Impression: normal Person is free of communicable tuberculosis: yes abnormal no I certify that I reviewed a record of this child's immunizations and transcribed it accurately: Date / / / / Staff Signature Record Presented was: Yellow California Immunization Record Out-of-state school record Other immunization record Specify: II. STATUS OF REQUIREMENTS A. All Requirements are met. / / Date B. Currently up-to-date, but more doses are due later. Needs follow-up. Exemption was granted for: C. Medical Reasons—Permanent D. Medical Reasons—Temporary E. Personal Beliefs III. 7th GRADE ENTRY A. All Requirements are met. Name Date Name Date B. Currently up-to-date, but more doses are due later. Needs follow-up. CDPH 286 (01/14) INSTRUCTIONS FOR SCHOOL OR CHILD CARE STAFF 1. Complete child’s name and address information section, or ask parent or guardian to complete this section only. (This form is not to be sent home or given to parents to complete.) 2. School or child care personnel then fill in date (month/day/year) of each immunization the student has received from the Immunization Record presented by the parent or guardian. (If the date consists only of month and year for some doses, fill in month/xx/year; however, if either measles, rubella or mumps (or MMR) was received in the month of the first birthday, month/day/year is required.) 3. Determine if immunization requirements have been met, using the California ‘‘Immunization Requirements for Grades K–12,’’ or ‘‘Immunization Requirements for Child Care,’’ (available from Immunization Coordinators in local health departments), or other requirements guide. 4. Complete the Documentation and Status of Requirements box. A. Fill in date and your signature as the staff member who reviewed and transcribed the immunization record presented by the parent or guardian. Check which type of record was presented. B. If the child has met all immunization requirements, check box A and write in date. C. If the child has not met all requirements, check box B. Child can be admitted only if up-to-date, e.g., no immunizations due currently. The child must be followed up as indicated in the ‘‘Guide to Immunization Requirements.’’ D. If a child is to be exempted for medical reasons, a doctor’s written statement is required; the statement must include which immunization(s) is to be exempted and the specific nature and probable duration of the medical condition. If the medical exemption is permanent, the requirement for the designated immunization(s) is met: check box A and box C.* If the medical exemption is temporary, check box B and box D; this child must be followed up.* E. If a child is to be exempted for reasons of personal beliefs, the parent or guardian must present documentation consistent with Health and Safety Code Section 120365, including documentation of all other required immunizations the child has received. All requirements are met; check box A and box E.* Applicable only in those jurisdictions where the Tuberculosis Assessment is required for school entry Personal Beliefs Affidavit to be Signed by Parent or Guardian—Tuberculosis I hereby request exemption of the child named on the front from the tuberculosis assessment requirement for school/child care center entry because this procedure(s) is contrary to my beliefs. I understand that should there be cause to believe that my child is infected with active tuberculosis or should there be a tuberculosis outbreak, my child may be temporarily excluded from school. Creencias Personales: Declaración Jurada Debe ser Firmada por el Padre o la Madre o el Guardián Solicito por la presente la dispensa de mi hijo, nombrado en el reverso, de los requisitos para la evaluación de la tuberculosis (tisis) de la entrada a la escuela ya que esta evaluación es opuesta a mis creencias. Comprendo que si hay razón para sospechar que mi hijo sufra de la tuberculosis activa o si hay un brote de la tuberculosis, mi hijo puede ser excluido de la escuela. Signature (Firma) Date (Fecha) * Names of all children who are exempt should be maintained on an exempt roster for immediate identification in case of disease outbreak in the community.
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