1. education
2. school

Reports due
October 15, 2014
Oc October
15, 2013
HOW TO COMPLETE THE KINDERGARTEN
IMMUNIZATION
ASSESSMENT
STEP 1: Download/Access the Kindergarten Worksheet and the Kindergarten
Immunization Requirements:




Kindergarten Immunization Assessment Worksheet (PM236A)
Guide to Immunizations Required for School Entry, Grades K-12
California School Immunization Record (Blue Card, PM-286)
‘New’ PBE Form (CDPH-8262)
These are available for download at: www.shotsforschool.org/reporting To order more Blue Cards, contact
your local health department. Some facilities have electronic systems and may not need the worksheet.
Note:





Report immunization status of ALL kindergarten students (traditional AND transitional) as of the date the report is completed.
For ungraded classes, report on entering students from age 4 years-9 months to age 5 years-9 months.
Do not report on pre-K students or after-care enrollees.
Submit one report for each school campus per year.
If a student has an exemption and is also a conditional entrant, please report the student as having an exemption only. If a student has a
permanent medical exemption and a personal beliefs exemption, report the student as having received a personal beliefs exemption only.
STEP 2: Determine Number of Doses Received by Vaccine Type for Each Student and
Enter into the Worksheet:
Enter each child's name or other identifier on the “WORK SHEET” provided (PM 236A). Then determine the
immunization status of each child (see process below) by reviewing each student's blue California School
Immunization Record (CSIR, PM-286), which must be included in the student's cumulative file. Be sure these
forms are up-to-date before proceeding.
A.
An "Unconditional Entrant" is a student who:
1.
MEETS all kindergarten immunization requirements by having:
Number of
Vaccine
Doses Required
Doses Req. if 1 dose
after 4 yrs. of age:
Polio
4
3
DTP/DT
5
4
Measles—containing vaccine ( at least 1 dose of MMR)
2
Hepatitis B
3
Varicella (or physician-documented varicella disease)
1
1
OR: 2. Presents a physician's statement of PERMANENT Medical Exemption (PME) for any doses that
have not been received;
OR: 3. Presents a valid Personal Beliefs Exemption (PBE):
 For entry before January 1, 2014: A signed statement of personal beliefs on the back of CA School
Immunization Record OR
 For entry on or after January 1, 2014: A completed ‘new’ PBE Form ( ‘Personal Beliefs Exemption
to Required Immunizations’, CDPH-8262)
For each student, check the appropriate box on the Kindergarten Worksheet: 1. All Immuns. OR 2. PME
If student is PBE, check only one of the following:
 a. Pre-Jan 2014 column - if a 2nd year transitional kindergartener with a personal beliefs exemption taken
prior to January 1, 2014.
 b. Health Care Practitioner column - if there is documentation of counseling from an authorized
health care practitioner in section A of the ‘new’ PBE Form (CDPH 8262) or its equivalent
 c. Religious column - if the parent had indicated a religious personal beliefs exemption in Section B
of the ‘new’ PBE Form or its equivalent
Examples - “Unconditional Entrants” Section of Kindergarten Worksheet
Unconditional Entrants
The child has:
Student Status
1. All Imms.
All required imms
PME
PBE – ‘pre Jan’
PBE –‘HP-counseled’
PBE – ‘Religious’
B.
2. PME
Type of PBE:
3. PBE
(3a+3b+3c)
3a. Pre-Jan 3b. Health pract
3c. Religious
2014
-Counseled
X
X
X
X
X
A "Conditional Entrant" is a student who DOES NOT meet the immunization requirements because:
1. they are ‘in process’ and have no received all required doses,
2. they have a temporary medical exemption, or
3. they are transfer student and have yet to receive their immunization documentation
‘Conditional entrants’ must be followed up to ensure they become fully-vaccinated.
For these students, check the 4. Cond. box on the Worksheet AND check mark the box for each vaccine (a.
Polio, b. DTP, c. MMR, d. Hepatitis B, e. Varicella) for which the child is missing doses.
Example – ‘Conditional Entrants” Section of Kindergarten Worksheet
Student Status
Missing Hep B, DTP
Transfer – no record
Temp PME – no MMR
Missing 1 DTP
4. Cond.
X
X
X
X
a. Polio
X
Conditional Entrants
- Dose not meet requirements for:
b. DTP
c. MMR
d. Hepatitis B
X
X
X
X
X
X
X
e. Varicella
X
2
Before reporting, review the worksheet for errors. Check that each ‘Unconditional Entrant’ has a single check
mark in either Column 1, 2, 3a, 3b, or 3c. In addition, all ‘Conditionals Entrants’ must have a check mark in
Column 4 plus one or more checkmarks in 4a, 4b, 4c, 4d, and 4e. No students should ever have a check mark
under both “Unconditional Entrants” and “Conditional Entrants”.
STEP 3: Login to the Kindergarten 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 Kindergarten link to open the Kindergarten Reporting page.
STEP 4: Completing & Submitting Your Report Online:
Reports due
October 15, 2014
Oc October 15,
2013
a. Login: Choose from the drop
down menus: School Type,
County, District (if public),
School Name and School
Address. Then enter the
Password: school and click the
Log in button.
Alternatively, enter your sevendigit school code (the last
seven digits of your CountyDistrict-School (CDS) code in
the School Code box, then
enter the password: school.
b. Confirm Kindergarten Status:
 If your school does not have kindergarten students enrolled this year, respond No to the question, “Do
you have kindergarten students enrolled this year?” and choose a reason from the drop down box.
Then answer whether your students are schooled at home and whether your school is an
online/virtual school. Then select Confirm and continue at the bottom to proceed.
 If your school does have kindergarten students enrolled this year, respond Yes to the question. Then
answer whether your students are schooled at home and whether your school is an online/virtual
school. Then select Confirm and continue at the bottom to proceed.
3





c. Complete the Report:
Enter the total Number of Kindergarten
Students Enrolled.
Transfer the Totals from the worksheet
into the corresponding spaces on the
report.*
Double check that the numbers are
correct:
Row 3, “Personal Beliefs Exemption to
any immunizations” will autosum
based on 3a+3b+3.
Row 1, 2, 3, and 4 must TOTAL
EXACTLY the “Number of K Students
Enrolled” and row 4 must be
accounted for by spaces 4a, 4b, 4c, 4d,
and/or 4e.
*If you are using Internet Explorer 10, you may need to click
in the box to enter information instead of using tab.
d. Submitting Your Report:
 Include your contact information as the
report submitter and enter a designated
school contact.
 Review your information for accuracy
and then select Submit.
 All reports must be submitted on or
before October 15th.
4
 Print/Save a copy for your records
by selecting Print Report or
Download Report (PDF). Retain
your worksheet for your records.
 If you will be reporting for another
school, select Logout to return to
the login page and repeat steps
1-4.
Congratulations, you have
completed the report online.
5
Kindergarten & 7th Grade Immunization Assessment
Frequently Asked Questions
1. Q: What is my login password?
A: For Kindergarten: school
For 7th Grade: shots
2. Q: I cannot find my School Name after selecting appropriate School Type (public or private) and
District (only if public). What should I do?
A: If your school is new, and it isn’t yet listed, you’re not required to report this year. If your school isn’t new,
please contact the CA Department of Education to confirm your school has the correct grade span, enrollment and
status. You may but are not required to submit a paper form which you can obtain from your local health
department.
3. Q: How do I print or download a copy for my records?
A: After you Submit the report, select Print Report or Download Report (PDF) before logging out. If you’ve
already logged out, view or print these instructions from the Login Page: Need to Confirm We Received Your
Submission or Print a Copy for Your Records? K | 7
4. Q: How can I be sure you received my submission?
A: View or print these instructions from the Login Page: Need to Confirm We Received Your Submission or Print a
Copy for Your Records? K | 7
5. Q: I already submitted my report but now realize I made a mistake. How can I correct the error(s) if I
have already submitted the report?
A: Once you re-login, select ‘Revise your Submitted Report’. Make your changes, then click ‘Submit’ to save and
submit your revised report. Changes can be made up until reporting closes.
6. Q: How can I send a copy of this form to my district office?
A: Make copy or download as described in Question 4 and send to District office.
7. I do not have internet capability. How can I complete this form?
A: Please contact your local health department (see Help section below) to request hard copy materials.
8. I have a student who is conditional for one vaccine and has an exemption. How do I report?
A: Report the student as having an exemption only.
9. I have a student who is has a permanent medical exemption for one vaccine and a personal beliefs
exemption for another. How do I report?
A: Report the student as having a personal beliefs exemption.
FAQs Regarding Transitional or Junior Kindergarten
8. Q: Are students in the transitional or junior kindergarten also subject to the kindergarten
immunization requirements?
A: Yes. Every child age 4-6 years old in kindergarten must meet the Kindergarten requirements or have
a valid exemption prior to admission to Kindergarten.
9. Q: How should a school report these transitional or junior kindergarten students for the
kindergarten annual immunization assessment report?
A: Record the status of every child in your Kindergarten on the form - the reporting process does not distinguish
transitional and traditional kindergarten students.
_____________________________________________________________________________________________
HELP If you need further assistance, please contact your local health department listed on the next page.
Rev. 09/14
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
GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY
Grades K-12
INSTRUCTIONS
Use this guide as a quick reference to help you determine whether children seeking admission to your
school meet California’s school immunization requirements. For the actual laws, see 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. If you have any questions, call the Immunization
Coordinator at your local health department.
IMMUNIZATION
REQUIREMENTS
To enter into public and private elementary and secondary schools (grades kindergarten through 12,
including transitional kindergarten), children under age 18 years must have immunizations.
VACCINE
REQUIRED DOSES
Polio
4 doses at any age, but... 3 doses meet requirement for ages 4–6 years if at
least one was given on or after the 4th birthday1; 3 doses meet requirement
for ages 7–17 years if at least one was given on or after the 2nd birthday.1
Diphtheria, Tetanus, and Pertussis
Age 6 years and under: DTP, DTaP or any combination of DTP or DTaP with
DT (diphtheria and tetanus) 5 doses at any age, but... 4 doses meet requirements for ages 4–6 years if at least one was on or after the 4th birthday.1
Age 7 years and older: Tdap, Td, or DTP, DTaP or any combination of these
4 doses at any age, but...3 doses meet requirement for ages 7–17 years if at
least one was on or after the 2nd birthday.1 If last dose was given before the
2nd birthday, one more (Tdap) dose is required.
Measles, Mumps, Rubella (MMR)
Age 4-6 years (kindergarten and above): 2 doses2 both on or after
1st birthday.1
7th grade: 2 doses2 both on or after 1st birthday.1
Age 7-17 years and not entering or advancing into 7th grade: 1 dose on or
after 1st birthday.1
Hepatitis B3
Age 4-6 years (kindergarten and above): 3 doses.
Varicella
1 dose4, 6
Tdap Booster (Tetanus, reduced
diphtheria, and pertussis)
7th grade: 1 dose on or after 7th birthday. 5, 7
Receipt of a dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement.
Two doses of measles-containing vaccine required. One dose of mumps and rubella-containing vaccine required; mumps
vaccine is not required for children 7 years of age and older.
3
Not required for 7th grade.
4
Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement.
5
Tdap, DTaP, or DTP given on or after 7th birthday will meet the requirement. Td does not meet the requirement.
6
2 dose varicella requirement for ages 13-17 years applies to transfer students who were not admitted to a California school
before July 1, 2001.
7
8th-12th grade students transferring from outside of California must meet the requirement.
1
2
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. Schools 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
NOT MEETING
REQUIREMENTS
Refer pupils who do not meet these State requirements to their physician or local health department. Give
families a written notice indicating which doses are lacking.
CONDITIONAL
ADMISSIONS
Children who lack one or more required vaccine doses that are not currently due may be admitted
on condition that they receive the remaining doses when due (Title 17, CCR Section 6035).
IMM-231 (4/14)
California Department of Public Health • Immunization Branch • ShotsForSchool.org
State of California—Health and Human Services Agency
California Department of Public Health
KINDERGARTEN IMMUNIZATION ASSESSMENT WORK SHEET
(Do Not Send In)
Each child should have either one check mark under column 1, 2 or 3 (and if a check under 3, then also a check under column 3a, 3b, or 3c) or
a check mark under column 4 (and if a check under 4, then also check marks under columns 4a, 4b, 4c, 4d, and/or 4e) never under both headings. (Use the K-12 Guide to Immunizations Required for School Entry to determine status.)
NOTE: The numbers and letters on these columns coincide with those on the SCHOOL SUMMARY SHEET.
UNCONDITIONAL ENTRANTS
CONDITIONAL ENTRANTS
NAME OR ID
— the child has:
Type of PBE:
—does not meet requirement for:
1.All Imms 2. PME1
a. Pre-Jan
3. PBE
(3a+3b+3c)
2
20143
b. Health
Pract.
c. Religious5 4. Cond.6 a. Polio
b. DTP
c. MMR d. Hep B e. Varicella7
Counseled4
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Subtotal this page (count check
marks)
Gr and Total all pages
1
COPY TO
SCHOOL
SUMMARY
SHEET
1.
2.
3.
3a.
3b.
3c.
4.
4a.
4b.
4c.
4d.
4e.
1.
2.
3.
3a.
3b.
3c.
4.
4a.
4b.
4c.
4d.
4e.
Permanent medical exemption (PME) to some or all immunizations
2
Personal beliefs exemption (PBE) to some or all immunizations; each child with a PBE should have only one type of PBE checked. The grand total of all check marks in
column 3 must equal the grand total of all check marks in column 3a+3b+3c.
3
PBE to some or all immunizations taken before January 1, 2014 (i.e., parent or guardian signed affidavit on back of CSIR)
4
Health Care Practitioner Counseled PBE to some or all immunizations taken on or after January 1, 2014; documentation of counseling from an authorized health care
practitioner in section A of CDPH 8262 or its equivalent
5
Religious PBE to some or all immunizations taken on or after January 1, 2014; the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262
6
Lacks one or more required immunizations
7
A conditional entrant for varicella is a child who has neither received the varicella vaccine
nor has health care provider-documented varicella disease or immunity.
PM 236A (7/14)
Page 1 of 2
UNCONDITIONAL ENTRANTS
NAME OR ID
— the child has:
1.All Imms 2. PME1
Type of PBE:
a. Pre-Jan
3. PBE
(3a+3b+3c)
CONDITIONAL ENTRANTS
2
2014
3
b. Health
Pract.
Counseled
—does not meet requirement for:
c. Religious5 4. Cond.6 a. Polio
b. DTP
c. MMR d. Hep B e. Varicella7
4
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Subtotal this page (count check marks) 1.
Gr and Total all pages
COPY TO
SCHOOL
SUMMARY
SHEET
1.
2.
3.
3a.
3b.
3c.
4.
4a.
4b.
4c.
4d.
4e.
2.
3.
3a.
3b.
3c.
4.
4a.
4b.
4c.
4d.
4e.
1
Permanent medical exemption (PME) to some or all immunizations
Personal beliefs exemption (PBE) to some or all immunizations; each child with a PBE should have only one type of PBE checked. The Grand Total of all check marks in
column 3 must equal the grand total of all check marks in column 3a+3b+3c.
3
PBE to some or all immunizations taken before January 1, 2014 (i.e., parent or guardian signed affidavit on back of CSIR)
4
Health Care Practitioner Counseled PBE to some or all immunizations taken on or after January 1, 2014; documentation of counseling from an authorized health care
practitioner in section A of CDPH 8262 or its equivalent
5
Religious PBE to some or all immunizations taken on or after January 1, 2014; the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262
6
Lacks one or more required immunizations
7
A conditional entrant for varicella is a child who has neither received the varicella vaccine
nor has health care provider-documented varicella disease or immunity.
2
PM 236A (7/14)
Page 2 of 2
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.