REMEMBER: IMMUNIZATIONS (VACCINES), OR A LEGAL EXEMPTION, ARE REQUIRED FOR CHILDREN TO ATTEND SCHOOL.

Size: px
Start display at page:

Download "REMEMBER: IMMUNIZATIONS (VACCINES), OR A LEGAL EXEMPTION, ARE REQUIRED FOR CHILDREN TO ATTEND SCHOOL."

Transcription

1 Department of District Nursing To: Parents/Guardians From: Nursing Services Re: Entrance into Kindergarten Fall 017 District Administration Office th Ave. North, Suite 100 St. Cloud, MN P F As you register your child for Kindergarten entrance, we would like you to be aware of the following: Minnesota Statute 11A.15 requires all students enrolled in public or private schools to be fully immunized against certain preventable communicable diseases. The attached immunization certificate must be completed and signed by a parent/guardian or physician/medical provider. A printed record of immunizations from your child s clinic is acceptable. If you are requesting an exemption, please use the Student Immunization Form (section B) to document your child s status. STATE LAW REQUIRES THIS FORM BE ON FILE IN YOUR CHILD S SCHOOL ON THE OPENING DAY OF SCHOOL IN THE FALL OF 017. Forms can found by going to Go to Student Services, then Health Services, then click on Health Documents and Forms on the left. There you will find the The Physical Form and the Immunization Form along with the Immunization Requirements for School. Children entering Kindergarten are generally required to have five DTP s (diphtheria, tetanus, pertussis), four Polios, two s (measles, mumps, rubella), two (chickenpox), and three Hepatitis B vaccinations. Physician/healthcare providers may recommend a Hepatitis A series. Some variations of the schedule may be acceptable. Physicians/healthcare providers may recommend a Hepatitis A series. Some variations of the schedule may be acceptable. Two (chickenpox) vaccinations, or proof (month/year) of chickenpox disease is required for Kindergarten. A physician/healthcare provider signature is needed in the medical exemption section of the Student Immunization Form (section A) to verify chickenpox disease. Exemptions will be allowed for children with medical contraindications or parents whose conscientiously held beliefs are opposed to immunizations. If you are requesting an exemption, please use the Student immunization Form (section B) to document your child s status. You must write in which immunizations your child is to be exempt from and the form must be notarized. Physical examinations are recommended for all Kindergarten students. Please take the physical examination form with you at the time of the examination for the physician/healthcare provider to complete. Please fill in the information at the top of the form prior to the appointment. This immunization and physical form need to be returned to your child s school by AUGUST 15 TH, 017. If the school has not received it by August 15 th, you will be contacted by the school nurse. If your child is not fully immunized, he/she will need to be up-to-date in order to attend school If you have further questions and/or information that you wish to discuss with the school nurse, please feel free to call the elementary school in your attendance area. REMEMBER: IMMUNIZATIONS (VACCINES), OR A LEGAL EXEMPTION, ARE REQUIRED FOR CHILDREN TO ATTEND SCHOOL.

2 Immunization Requirements Are Your Kids Ready? Minnesota s Immunization Law Use this chart as a guide to determine which vaccines are required to enroll in child care, early childhood programs, and school (public or private). Find the child s age/grade level and look to see if your child had the number of shots shown by the checkmarks under each vaccine. The table on the back shows the ages when doses are due. Birth through 4 years Early childhood programs & Child care Age: 5 through 6 years For Kindergarten 3 Age: 7 through 11 years For 1 st through 6 th grade Age: 1 years and older For 7 th through 1 th grade Hepatitis A (Hep A) Hepatitis B (Hep B) Polio 5 Polio Not required after 4 months. If the child has already had chickenpox disease, varicella shots are not required. If the disease occurred after 010, the child s doctor must sign a form confirming disease. First graders who are 6 years old and younger must follow the polio and DTaP/DT schedules for kindergarten. Fifth shot of DTaP not needed if fourth shot was after age 4. Final dose of DTaP on or after age 4. Fourth shot of polio not needed if third shot was after age 4. Final dose of polio on or after age 4. Need proof of at least three tetanus and diphtheria containing doses. If up to date on DTaP/DT series, no additional doses needed. An alternate two-shot schedule of hepatitis B may also be used for kids age 11 through 15 years. One dose of Tdap is required beginning at 7th grade. Also need proof of at least two tetanus and diphtheria containing doses (DTaP/DT/Td). If a child received Tdap prior to 7th grade, another dose of Tdap is not needed. One dose is required beginning at 7th grade. The booster dose is usually given at 16 years. Exemptions Polio Hib Pneumococcal Immunizations recommended but not required: Influenza Annually for all children age 6 months and older Rotavirus For infants Looking for Records? DTaP/DT 1 Hepatitis B DTaP/DT 4 Hepatitis B 6 tetanus and diphtheria containing doses Hepatitis B 7 Tdap 8 & at least tetanus and diphtheria containing doses Polio Meningococcal 9 & booster Human papillomavirus At age 11-1 years To enroll in child care, early childhood programs, and school in Minnesota, children must show they ve had these immunizations or file a legal exemption. Parents may file a medical exemption signed by a health care provider or a non-medical exemption signed by a parent/guardian and notarized. For copies of your child s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at Minnesota Department of Health, Immunization Program ID# 5799 (4/017)

3 Birth 4 6 When to Get Vaccines Birth to 16 Years YEARS 11-1 YEARS 16 YEARS Hep B Hep B* (1- months after 1st hep B dose) Hep B* (6-18 months) HPV** RV RV RV* DTaP DTaP DTaP DTaP (15-18 months) DTaP Tdap Hib Hib* Hib Hib (1-15 months) MCV MCV PCV PCV PCV PCV (1-15 months) IPV IPV IPV (6-18 months) IPV (1-15 months) (1-15 months) Hep A ( doses at least 6 months apart) Concerned about cost? Free or low cost vaccines are available. Talk to your doctor or clinic. Influenza (each fall) It s not too late! If your child has fallen behind on their vaccinations, talk to your doctor or clinic to catch them up. Minnesota law requires written proof of certain vaccinations for children in child care, early childhood programs, and school. However, if a child has a medical reason or if his/her parents are conscientiously opposed to any or all of the vaccinations, a legal exemption is available. Children with certain medical conditions may need additional vaccines (e.g., pneumococcal or meningococcal). Talk to your doctor or clinic. Immunization Program or Pregnant? Protect yourself and your baby from whooping cough, get a Tdap vaccination between 7 and 36 weeks gestation. Talk to your doctor. *The number of doses depends on the product your doctor uses. **Two doses for 9 to 14 year olds; three doses for 15 to 6 year olds. For copies of your child's immunization records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at Key to vaccine abbreviations DTaP/Td/Tdap = diphtheria, pertussis, tetanus Hib = Haemophilus influenzae type b Hep B = hepatitis B Hep A = hepatitis A IPV = polio MCV = meningococcal = measles, mumps, rubella PCV = pneumococcal RV = rotavirus ID# 5799 (4/017)

4 Student Immunization Form Student Name Birthdate Student Number Minnesota law requires children enrolled in school to be immunized against certain diseases or file a legal medical or conscientious exemption. FOR SCHOOL USE ONLY ( ) Complete; booster required in ( ) In process; 8 mos. expires ( ) Medical exemption for ( ) Conscientious objection for ( ) Parental/guardian consent Parent/Guardian: You may attach a copy of the child s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section A to document medical exemptions (including a history of varicella disease) and B to document a conscientious exemption. Additionally, if a parent or guardian would like to give permission to the school to share their child s immunization record with Minnesota s immunization information system, they may sign section 3 (optional). For updated copies of your child s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at or School Personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it. Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space. Type of Vaccine DO NOT USE () or () 1st Dose nd Dose 3rd Dose 4th Dose 5th Dose Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT) for children age 6 years and younger final dose on or after age 4 years Tetanus and Diphtheria (Td) for children age 7 years and older 3 doses of Td required for children not up to date with DTaP, DTP, or DT series above Tetanus, Diphtheria and Pertussis (Tdap) for children in 7th - 1th grade Polio (IPV, OPV) final dose on or after age 4 years Measles, Mumps, and Rubella () minimum age: on or after 1st birthday Hepatitis B (hep B) (chickenpox) minimum age: on or after 1st birthday vaccine or disease history required Meningococcal (MCV, MPSV) for children in 7th - 1th grade booster given at age 16 years Recommended Human Papillomavirus (HPV) Hepatitis A (hep A) Influenza (annually for children 6 months and older) 4th dose not required if 3rd dose was given on or after the 4th birthday 5th dose not required if 4rd dose was given on or after the 4th birthday Additional exemptions: Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the minimum requirements of the law. Students in grades 7-1: A Tdap at age 11 years or later is required for students in grades 7-1. If a child received Tdap at age 7-10 years another dose is not needed at age 11-1 years. However, if it was only a Td, a Tdap dose at age 11-1 years is required. Students years of age: A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the alternative -dose schedule. Students 18 years of age or older: Do not need polio vaccine. Developed by the Minnesota Department of Health - Immunization Program (1/13) #

5 Student Name Instructions, please complete: Box 1 to certify the child s immunization status Box to file an exemption (medical or concientious) Box 3 to provide consent to share immunization information (optional) 1. Certify Immunization Status. Complete A or B to indicate child s immunization status. A. Received all required immunizations: I certify that this student has received all immunizations required by law. Signature of Parent / Guardian OR Physician / Public Clinic B. Will complete required immunizations within the next 8 months: I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B, varicella, measles, mumps, and rubella and will complete his/her diphtheria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months. The dates on which the remaining doses are to be given are: Signature of Physician / Public Clinic. Exemptions to School Immunization Law. Complete A and/or B to indicate type of exemption. A. Medical exemption: No student is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a student to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement: I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s): B. Conscientious exemption: No student is required to have an immunization that is contrary to the conscientiously held beliefs of his/ her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the student or others they come in contact with. In a disease outbreak schools may exclude children who are not vaccinated in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s): Signature of physician/nurse practitioner/physician assistant *History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in (year) Signature of physician/nurse practitioner/physician assistant (If disease occured before September 010, a parent can sign.) Signature of parent or legal guardian Subscribed and sworn to before me this: day of 0 Signature of notary 3. Parental/Guardian Consent to Share Immunization Information (optional): Your child s school is asking your permission to share your child s immunization documentation with MIIC, Minnesota s immunization information system, to help better protect students from disease and allow easier access for you to retrieve your child s immunization record. You are not required to sign this consent; it is voluntary. In addition, all the information you provide is legally classified as private data and can only be released to those legally authorized to receive it under Minnesota law. I agree to allow school personnel to share my student s immunization documentation with Minnesota s immunization information system: Signature of parent or legal guardian Date Developed by the Minnesota Department of Health - Immunization Program (1/13) #

6 **Please mail form directly to the school your child is attending by August 15. ST. CLOUD AREA SCHOOL DISTRICT 74 PHYSICAL FORM This form is confidential. Name Male Female Birthdate Address Phone Parent/Guardian Physician/Healthcare Provider Dentist Last physical exam Last dental exam Allergy (specify) Asthma Chicken Pox (Disease) Congenital Defect (specify) Diabetes Heart Condition Neurologic (specify) Orthopedic (specify) Year Significant Past History ADHD ADD Developmental Delay Seizure History Vision Glasses Yes Hearing Surgeries (specify) T & A Myringotomy Tubes, Hernia Other Year Health Examination (To be completed by Physician/Healthcare Provider) Examining Physician s/healthcare Provider s Name (Print) Ht. Wt. BMI Pulse BP Urinalysis HGB Eyes Ears Orthopedic/Scoliosis Nose Skin Throat Allergies (if so, what?) Glands Lungs Nutrition Heart Serious Illnesses Nervous System Please review/record immunizations on reverse side and update for school requirements as needed. Does student require medication on a daily or episodic routine? Name of medication: Dose: Frequency: Condition being treated: *Please include a separate Physician/Healthcare Provider s order if medication will be taken at school. Significant Development History History of: Hearing Problem Speech Problem History of: Social or Emotional Problem List conditions which may limit participation in: A. Classroom activity B. Physical education C. Competitive sports Any special health problems, recommendations and/or comments Immunization(s) given today Approved for: Full Activity Limited Activity Date Examining Physician/Healthcare Provider I hereby release this information to the Health Service of District 74 and give the licensed school nurse permission to clarify the information with the Physician/Healthcare Provider if the need arises. PARENT/GUARDIAN SIGNATURE NS16.5 Revised 1/16

HOLDINGFORD PUBLIC SCHOOLS ISD #738 P.O. Box 250, Holdingford, MN

HOLDINGFORD PUBLIC SCHOOLS ISD #738 P.O. Box 250, Holdingford, MN HOLDINGFORD PUBLIC SCHOOLS ISD #738 P.O. Box 250, Holdingford, MN. 56340 Chris Swenson Angela Safran Jim Stang Beth Heinze Superintendent Secondary Principal Elementary Principal Business Manager 320-746-2196

More information

HEALTH INFORMATION FORM

HEALTH INFORMATION FORM St. Michael Albertville STUDENT INFORMATION Name: School: HEALTH INFORMATION FORM Grade: DOB: HEALTH INFORMATION Does your child have any health problems (i.e. Asthma, Diabetes, ADHD, Heart Condition,

More information

Early Childhood Screening Consent

Early Childhood Screening Consent Early Childhood Screening Consent Child s Name: (For office use only) MARSS other ID: Parent/Guardian Name(s): Birthdate: Early childhood developmental screening helps a school district identify children

More information

Dreamers Child Care Enrollment Application

Dreamers Child Care Enrollment Application Dreamers Child Care Enrollment Application Child s Full Name Gender Birth Date Address Home Phone Chronic Physical Problems / Pertinent Developmental Information / Special Accommodations Needed Previous

More information

THURGOOD MARSHALL ACADEMY PCHS ATHLETIC INFORMATION PACKET SY

THURGOOD MARSHALL ACADEMY PCHS ATHLETIC INFORMATION PACKET SY THURGOOD MARSHALL ACADEMY PCHS ATHLETIC INFORMATION PACKET SY 2015-2016 THE INFORMATION CONTAINED IN THIS PACKET MUST BECOMPLETED BY BOTH THE STUDENT ATHLETE AND PARENT/GUARDIAN AND RETURNED TO MRS. THOMPSON,

More information

The following steps are required to complete re-enrollment:

The following steps are required to complete re-enrollment: RE-ENROLLMENT PACKET The following steps are required to complete re-enrollment: Complete IP Re-Enrollment Forms (Online only Information provided in letter and on page 2) Submit updated health documents

More information

Changes for the School Year. The addition of NINTH grade to the requirement for four (4) doses of diphtheria, tetanus, and pertussis.

Changes for the School Year. The addition of NINTH grade to the requirement for four (4) doses of diphtheria, tetanus, and pertussis. February 19, 2013 Dear Immunization Provider: In accordance with South Carolina Code of Laws, Section 44-29-180, and State Regulation 61-8, the 2013-2014 "Required Standards of Immunization for School

More information

I. In accordance with Virginia Code relative to enrollment of certain children in public schools:

I. In accordance with Virginia Code relative to enrollment of certain children in public schools: Immunization Requirements I. In accordance with Virginia Code relative to enrollment of certain children in public schools: A. Children not properly immunized in accordance with the Virginia Department

More information

Utah s Immunization Rule Individual Vaccine Requirements

Utah s Immunization Rule Individual Vaccine Requirements Utah s Immunization Rule Individual Vaccine Requirements Which vaccines are required for school entry in Utah? Grades K-6: 5 doses DTaP (4 doses if the 4 th dose was given after the 4 th birthday) 4 doses

More information

YMCA School Age Programs 2017

YMCA School Age Programs 2017 YMCA School Age Programs 2017 Child Information Forms Today s / / Please check the session your child will attend: AM only PM only AM and PM Part-time 5 visit AM PM Child s First Name MI Last Name Male

More information

January Dear Kindergarten Family,

January Dear Kindergarten Family, January 2017 Dear Kindergarten Family, I am delighted to welcome you to the Wayzata Public Schools at the beginning of your child s educational journey! There has never been a more exciting time to be

More information

School Year IN State Department of Health School Immunization Requirements Updated March to 5 years old

School Year IN State Department of Health School Immunization Requirements Updated March to 5 years old 2013 2014 School Year IN State Department of Health School Immunization Requirements Updated March 2013 3 to 5 years old Kindergarten Grades 1 to 5 Grades 6 to 10 Grades 11 to 12 (Hepatitis B) 4 DTaP (Diphtheria,

More information

Healthy People 2020 objectives were released in 2010, with a 10-year horizon to achieve the goals by 2020.

Healthy People 2020 objectives were released in 2010, with a 10-year horizon to achieve the goals by 2020. Appendix 1: Healthy People 2020 Immunization-related Objectives Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For three decades, Healthy

More information

STANWOOD-CAMANO SCHOOL DISTRICT REQUEST FOR PART-TIME ATTENDANCE OR ANCILLARY SERVICES FROM PRIVATE SCHOOL PUPIL

STANWOOD-CAMANO SCHOOL DISTRICT REQUEST FOR PART-TIME ATTENDANCE OR ANCILLARY SERVICES FROM PRIVATE SCHOOL PUPIL STANWOOD-CAMANO SCHOOL DISTRICT REQUEST FOR PART-TIME ATTENDANCE OR ANCILLARY SERVICES FROM PRIVATE SCHOOL PUPIL 114 F2 Students Please complete ALL information: Name of Pupil Grade Address of Pupil City

More information

FULL DAY Application Checklist

FULL DAY Application Checklist Batesville Primary School 760 State Road 46 West Batesville, IN 47006 812-934-4509 www.batesvilleinschools.com/bps Student s Name Last First Middle 2016-2017 FULL DAY Application Checklist The following

More information

Immunization Requirements for School Entry - Ohio

Immunization Requirements for School Entry - Ohio Immunization Requirements for School Entry - Ohio Kindergarten through 12 th Grade Andrew Heffron Cuyahoga County Board of Health This information will help your school better understand Immunization entry

More information

Changes for the School Year

Changes for the School Year February 8, 2018 Dear Immunization Provider: In accordance with South Carolina Code of Laws, Section 44-29-180, and South Carolina Regulation 61-8, the 2017-2018 "Required Standards of Immunization for

More information

In order to enter St. Catherine of Siena School, all NEW students (Grades 1 5) must have (1) a pre entrance physical and (2) completed immunizations.

In order to enter St. Catherine of Siena School, all NEW students (Grades 1 5) must have (1) a pre entrance physical and (2) completed immunizations. ST. CATHERINE OF SIENA SCHOOL Middle States Accredited 39 E. Bradford Avenue, Cedar Grove, NJ 07009 Telephone 973 239 6968 Fax 973 239 1008 www.scs school cedargrovenj.org TO: Parents of NEW Students Grades

More information

White Plains YMCA 2016 Summer Camp Registration Form

White Plains YMCA 2016 Summer Camp Registration Form White Plains YMCA 2016 Summer Camp Registration Form Camper Information Child s First Name: Child s Last Name: Date of Birth: Gender: Age: S L XL What grade will your child be entering in the Fall of 2016?:

More information

Utah Immunization Guidebook

Utah Immunization Guidebook Utah Immunization Guidebook 2017 2018 For Schools, Early Childhood Programs and Healthcare Providers UTAH IMMUNIZATION GUIDEBOOK INTRODUCTION The Utah Immunization Program and the Utah State Office of

More information

kernfamilyhealthcare.com. Si necesita esta información en español, por favor llámenos.

kernfamilyhealthcare.com. Si necesita esta información en español, por favor llámenos. Together in... p revention Preventive Care Gu id e Kern Family Health Care wants you to get good health care. These preventive care guidelines help you stay healthy by preventing diseases or by finding

More information

I certify that the information provided on this form is correct and verifiable. Month Day Year

I certify that the information provided on this form is correct and verifiable. Month Day Year Certificate of Immunization Status (CIS) DOH 48-0 January 05 Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System. Child s Last

More information

Utah Immunization Guidebook

Utah Immunization Guidebook Utah Immunization Guidebook 2017 2018 For Schools, Early Childhood Programs and Healthcare Providers UTAH IMMUNIZATION GUIDEBOOK INTRODUCTION The Utah Immunization Program and the Utah State Board of Education

More information

CALIFORNIA CODE OF REGULATIONS TITLE 17, DIVISION 1, CHAPTER 4

CALIFORNIA CODE OF REGULATIONS TITLE 17, DIVISION 1, CHAPTER 4 CALIFORNIA CODE OF REGULATIONS TITLE 17, DIVISION 1, CHAPTER 4 Article 1. Definitions 6000. Admission. Admission means a pupil's first entry in a given public or private elementary or secondary school,

More information

131. Public school enrollees' immunization program; exemptions

131. Public school enrollees' immunization program; exemptions TITLE 14. EDUCATION PART I. FREE PUBLIC SCHOOLS CHAPTER 1. DEPARTMENT OF EDUCATION SUBCHAPTER II. POWERS AND DUTIES 14 Del. C. 131 (2007) 131. Public school enrollees' immunization program; exemptions

More information

RE-REGISTRATION FORM

RE-REGISTRATION FORM RE-REGISTRATION FORM (please print) Name of Child: Male / Female Home Phone #: street city/state/zip Date of Birth: E-mail address: Second e-mail: Mother s Social Security #: Employer s Father s Social

More information

Grand Island Central School District 1100 Ransom Road, Grand Island, NY 14072 (716) 773-8800 www.grandislandschools.org CONSENT TO RELEASE EDUCATIONAL RECORDS To: I. The undersigned (VI) authorizes (check

More information

Public Health Law Sections (PHL) 2164

Public Health Law Sections (PHL) 2164 Public Health Law Sections (PHL) 2164 School Immunization Requirements Update Robin Stiles-Tice March 19, 2018 March 19, 2018 2 Haemophilus influenzae type B (Hib) and Pneumoccocal (PCV) Vaccines Interval

More information

School Immunization Requirements IN State Department of Health School Year FAQ s

School Immunization Requirements IN State Department of Health School Year FAQ s Requirements & Compliance School Immunization Requirements IN State Department of Health 2014-2015 School Year FAQ s 1. Are there any new required immunizations for the 2014-2015 school year? Yes. Two

More information

Minnesota s School Immunization Law: Questions and Answers

Minnesota s School Immunization Law: Questions and Answers Minnesota s School Immunization Law: Questions and Answers Minnesota Statutes Section 121A.15 & Minnesota Rules Chapter 4604 Minnesota Department of Health Immunization Program 625 N. Robert Street P.O.

More information

Immunization Records. childrens.memorialhermann.org CARE /13

Immunization Records. childrens.memorialhermann.org CARE /13 Immunization Records childrens.memorialhermann.org 713.222.CARE 4400209-4/13 Personal Health Record of The Woodlands Contact Information Date and time of birth Place of birth Pediatrician name, phone number

More information

EARLY CHILDHOOD DEVELOPMENT & EDUCATION

EARLY CHILDHOOD DEVELOPMENT & EDUCATION A division of Pawsitively Bassett, Inc. EARLY CHILDHOOD DEVELOPMENT & EDUCATION 08-09 67 N. Monroe St., Spokane WA 9908 www.nlcpreschool.com (509) 8-00 Dear Parents, Thank you, for your interest in the

More information

Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.

Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns. Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York 12604 Please contact us at health@vassar.edu for any questions/concerns. This form must be submitted directly to the Health Service by July

More information

Schools. Kindergarten

Schools. Kindergarten 1 of 5 7/29/2014 4:14 PM Schools North Carolina law requires all children in the state to receive certain immunizations. Records are checked when children enter school or child care. Kindergarten Vaccination

More information

Proof of residency in East Orange is mandatory (see Residency Requirements)

Proof of residency in East Orange is mandatory (see Residency Requirements) Pre-K Registration Requirements Child must be at least 3 or 4 years old by October 1st of the current school year Immunization (shot records) are mandatory Age appropriate vaccinations for children entering

More information

Public Health Law 2164

Public Health Law 2164 Public Health Law 2164 Overview of School Immunization Requirements March 21, 2017 March 21, 2017 2 Summary of Changes NYS Immunization School Requirements for 2017-2018 Polio and varicella vaccine: Requirements

More information

Dear Parents. To obtain your child s immunisation history you can:

Dear Parents. To obtain your child s immunisation history you can: Dear Parents The Public Health Act require schools and child care centres to keep information about students immunisation records with respect to diphtheria, pertussis (whooping cough), polio, haemophilus

More information

School Year ALASKA CHILD CARE & SCHOOL IMMUNIZATION REQUIREMENT CHANGES

School Year ALASKA CHILD CARE & SCHOOL IMMUNIZATION REQUIREMENT CHANGES 2009 2010 School Year ALASKA CHILD CARE & SCHOOL IMMUNIZATION REQUIREMENT CHANGES EFFECTIVE JULY 1, 2009 ALASKA IMMUNIZATION PROGRAM (907) 269-8000 OR 1-888-430-4321 Varicella: Immunization Documentation

More information

CHILD INFORMATION RECORD

CHILD INFORMATION RECORD CHILD INFORMATION RECORD State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing Instructions: Unless otherwise indicated, all requested information must be provided.

More information

Public Health Law 2164

Public Health Law 2164 Public Health Law 2164 Overview of School Immunization Requirements March 17, 2017 March 17, 2017 2 Haemophilus influenzae type B (Hib) and Pneumoccocal (PCV) Vaccines Interval Requirements for Pre-kindergarten

More information

MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE MEDICATION ADMINISTRATION AUTHORIZATION FORM

MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE MEDICATION ADMINISTRATION AUTHORIZATION FORM Child Care Program: MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE MEDICATION ADMINISTRATION AUTHORIZATION FORM This form must be completed fully in order for child care providers and staff

More information

5. Statement of Applicant Health

5. Statement of Applicant Health 5. Statement of Applicant Health Applicant Name: Date of Examination: Height: Weight: Blood Type (If known): Physician must answer each of the following questions. To be completed by attending physician.

More information

Minnesota s School Immunization Law: Questions and Answers. Minnesota Statutes Section 121A.15 & Minnesota Rules Chapter 4604

Minnesota s School Immunization Law: Questions and Answers. Minnesota Statutes Section 121A.15 & Minnesota Rules Chapter 4604 Minnesota s School Immunization Law: Questions and Answers Minnesota Statutes Section 121A.15 & Minnesota Rules Chapter 4604 Minnesota Department of Health Immunization Program 625 N. Robert Street P.O.

More information

APPENDIX EE VACCINE STATUS AND DATE

APPENDIX EE VACCINE STATUS AND DATE VACCINE STATUS AND DATE Vaccine Status, Date is a ten-character field which presents information about each of the vaccines required for children. For most cases, the first character tells the vaccine

More information

WESTFIELD PUBLIC SCHOOLS 5320 IMMUNIZATION

WESTFIELD PUBLIC SCHOOLS 5320 IMMUNIZATION WESTFIELD PUBLIC SCHOOLS PUPILS WESTFIELD, NEW JERSEY 5320 Regulations follow Page 1 of 1 5320 IMMUNIZATION In order to safeguard the school community from the spread of certain communicable diseases and

More information

Student Health Medical Forms

Student Health Medical Forms LEHIGH UNIVERSITY Student Health edical Forms This form must be PRINTED, completed in its entirety and the original sent to: LEHIGH UNIVERSITY Health & Wellness Center 36 University Drive, Johnson Hall

More information

Student Health Center Phone: Fax:

Student Health Center Phone: Fax: Dear Perspective Student: On behalf of the Health Services team we would like to welcome you to Livingstone College. This letter is an aid to help you get your health records completed and turned in 30

More information

New Jersey Department of Health Vaccine Preventable Disease Program Childhood and Adolescent Recommended Vaccines

New Jersey Department of Health Vaccine Preventable Disease Program Childhood and Adolescent Recommended Vaccines New Jersey Department of Health Vaccine Preventable Disease Program Childhood and Adolescent Recommended Vaccines Antigens Vaccine Approved Age Daptacel Diphtheria, Tetanus, and acellular Pertussis (DTaP)

More information

ARKANSAS STATE BOARD OF HEALTH

ARKANSAS STATE BOARD OF HEALTH ARKANSAS STATE BOARD OF HEALTH RULES AND REGULATIONS PERTAINING TO IMMUNIZATION REQUIREMENTS Promulgated Under the Authority of Ark. Code Ann. 20-7-109, 6-18-702, 6-60-501-504, and 20-78-206. By the Arkansas

More information

WELLNESS CENTER Student Health Services (434) FAX (434)

WELLNESS CENTER Student Health Services (434) FAX (434) Page 1 WELLNESS CENTER Student Health Services (434) 223-6167 FAX (434) 223-7071 New Student Health Form The staff at Student Health are dedicated to providing you with high-quality health care designed

More information

UNIVERSAL CHILD HEALTH RECORD Endorsed by: American Academy of Pediatrics, New Jersey Chapter New Jersey Academy of Family Physicians New Jersey Department of Health SECTION I - TO BE COMPLETED BY PARENT(S)

More information

POPE JOHN PAUL II REGIONAL CATHOLIC ELEMENTARY CERTIFICATE OF IMMUNIZATION

POPE JOHN PAUL II REGIONAL CATHOLIC ELEMENTARY CERTIFICATE OF IMMUNIZATION POPE JOHN PAUL II REGIONAL CATHOLIC ELEMENTARY DATE: STUDENT NAME: GRADE ENTERING PJPII: PHONE: DATE OF BIRTH: SCHOOL YEAR: CERTIFICATE OF IMMUNIZATION The Pennsylvania School Health Law states: The following

More information

301 W. Alder, Missoula, MT or

301 W. Alder, Missoula, MT or 301 W. Alder, Missoula, MT 59802 406-258-4745 or 406-258-3363 Routine Immunizations are available on a walk-in basis: Mondays, Tuesdays, Thursdays, and Fridays from 9:00am to 4:30pm Wednesdays, 10:00am-4:30pm

More information

1.0 PURPOSE 2.0 REGULATORY AUTHORITY

1.0 PURPOSE 2.0 REGULATORY AUTHORITY ARKANSAS DEPARTMENT OF EDUCATION RULES GOVERNING KINDERGARTEN THROUGH 12 TH GRADE IMMUNIZATION REQUIREMENTS IN ARKANSAS PUBLIC SCHOOLS Emergency Adoption March 2015 1.0 PURPOSE 1.01 The purpose of these

More information

Grow & Stay Healthy Guidelines to Live By

Grow & Stay Healthy Guidelines to Live By Grow & Stay Healthy Guidelines to Live By Raising a child can be a lot of work! Trying to remember when to take them to the doctor or which immunizations they need can be a little confusing. Follow the

More information

GO GOLD. with Go365 GET ACTIVE LIVE HEALTHY ENJOY REWARDS

GO GOLD. with Go365 GET ACTIVE LIVE HEALTHY ENJOY REWARDS GO GOLD with Go365 GET ACTIVE LIVE HEALTHY ENJOY REWARDS Start earning points and living your healthiest life January 1, 2018 Gold is the New Silver We appreciate you participating in the Humana Go365

More information

Lesson 3: Immunizations

Lesson 3: Immunizations K-W-L Graphic Organizer K (Know) What do you know about W (Want) What do you want to know about L (Learned) What did you learn about Glossary 1. antibodies: proteins created by the immune system to fight

More information

Student Health Services 881 Commonwealth Ave, West / Student Information (To be completed by the student) Student Name Last First Middle

Student Health Services 881 Commonwealth Ave, West / Student Information (To be completed by the student) Student Name Last First Middle Medical Clearance The following information must be completed on the medical history form, if any information is missing the form will be considered incomplete and will not be processed. If you have questions,

More information

Student Full Name: Date of Birth:

Student Full Name: Date of Birth: Student Medical Form This form is to be completed for new students upon admission, and returning students prior to starting grades 3, 6, and 9. Students participating in athletics must complete form every

More information

Who makes these rules? 04/19/2013. Guidelines for vaccine schedules Vaccine information materials Worksheets for assessing immunization i records

Who makes these rules? 04/19/2013. Guidelines for vaccine schedules Vaccine information materials Worksheets for assessing immunization i records 2013 Childcare Provider Immunization Training Please sign in, take a packet and pretest Objectives Know immunization exemptions allowed in Nevada Identify immunizations required and recommended for childcare

More information

Your completed Health Record and any laboratory results must be uploaded to the Student Health Portal at: shac.usciences.edu

Your completed Health Record and any laboratory results must be uploaded to the Student Health Portal at: shac.usciences.edu Box 23; 600 South 43rd Street; Philadelphia PA 19104 Phone: (215) 596-8980 2017-2018 STUDENT HEALTH RECORD SUMMER/FALL 2017 DUE DATE: AUGUST 4, 2017 Your Student Health Record is to be completed and submitted

More information

FLORIDA DEPARTMENT OF EDUCATION DOE INFORMATION DATA BASE REQUIREMENTS VOLUME I: AUTOMATED STUDENT INFORMATION SYSTEM AUTOMATED STUDENT DATA ELEMENTS

FLORIDA DEPARTMENT OF EDUCATION DOE INFORMATION DATA BASE REQUIREMENTS VOLUME I: AUTOMATED STUDENT INFORMATION SYSTEM AUTOMATED STUDENT DATA ELEMENTS Vaccine Status, Date Definition/Domain Vaccine Status, Date is a ten-character field which presents information about each of the vaccines required for children. For most cases, the first character tells

More information

IMMUNIZATION OF PUPILS IN SCHOOL

IMMUNIZATION OF PUPILS IN SCHOOL R 5320 IMMUNIZATION A. Immunizations on Admission IMMUNIZATION OF IN SCHOOL 1. No Principal shall knowingly admit or retain any pupil who has not submitted acceptable evidence of immunization according

More information

Student Immunization Record Part I Student Information

Student Immunization Record Part I Student Information Student Immunization Record Part I Student Information Student ID#: Last Name: First Name: _ MI: Date of Birth: Sex: Phone Number: E-mail: Parts II - IV are to be completed by a Healthcare provider. All

More information

7.0 Nunavut Childhood and Adult Immunization Schedules and Catch-up Aids

7.0 Nunavut Childhood and Adult Immunization Schedules and Catch-up Aids 7.0 Nunavut Childhood and Adult Immunization Schedules and Catch-up Aids Contents Introduction Nunavut Recommended Childhood Immunization Schedule Nunavut Routine Adult Immunization Schedule Nunavut Immunization

More information

SEPTEMBER 2015 MEDICAL REQUIREMENTS FOR CHILD CARE AND NEW SCHOOL ENTRANTS (PUBLIC, PRIVATE, PAROCHIAL, CHILD CARE CENTERS AND SCHOOLS)

SEPTEMBER 2015 MEDICAL REQUIREMENTS FOR CHILD CARE AND NEW SCHOOL ENTRANTS (PUBLIC, PRIVATE, PAROCHIAL, CHILD CARE CENTERS AND SCHOOLS) Department of Health and Mental Hygiene Mary T. Bassett, MD, MPH nyc.gov/health Department of Education ~ Carmen Farina schools.nyc.gov/ SEPTEMBER 2015 MEDICAL REQUIREMENTS FOR CHILD CARE AND NEW SCHOOL

More information

Immunization Requirements

Immunization Requirements Please Read Carefully. Health Care Provider: A physician (MD or DO), Nurse Practitioner, Physician s Assistant, or Registered Nurse. English: All immunization forms and laboratory reports must be submitted

More information

Daycare, school entry and school program immunization report. Data for school year 2015/16

Daycare, school entry and school program immunization report. Data for school year 2015/16 Daycare, school entry and school program immunization report Data for school year 2015/16 Table of Contents Table of Content2 1. Introduction... 1 2. Data Source... 1 3. Limitations... 2 4. Daycare - Proof

More information

IMMUNIZATION & PHYSICAL FORM

IMMUNIZATION & PHYSICAL FORM Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U PLEASE UPLOAD

More information

2019 Jr. Adventure Camp and Jr. Mustangs Camp Registration Form

2019 Jr. Adventure Camp and Jr. Mustangs Camp Registration Form 2019 Jr. Adventure Camp and Jr. Mustangs Camp Registration Form Camper s Name M / F Date of Birth Parent s Email Address Street Address City State Zip Parent/Guardian Home Phone Cell Phone Address (if

More information

STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943

STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943 Page 1 STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943 NEW STUDENT HEALTH FORM The staff at Student Health are dedicated to providing you with high-quality health care designed specifically

More information

Preventive care is important at every age. Making good health choices now can boost your health and well-being for a lifetime.

Preventive care is important at every age. Making good health choices now can boost your health and well-being for a lifetime. Adult Recommendations Preventive care is important at every age. Making good health choices now can boost your health and well-being for a lifetime. Asthma and COPD Well-Child Visits Children s Immunization

More information

School Nurse Regional Update School Year Immunizations COLORADO IMMUNIZATION BRANCH

School Nurse Regional Update School Year Immunizations COLORADO IMMUNIZATION BRANCH School Nurse Regional Update 2017-18 School Year Immunizations COLORADO IMMUNIZATION BRANCH Talking Points Child Care Immunizations K through 12 th Grade Immunizations Official Medical and Non-Medical

More information

Preventive Care Guide

Preventive Care Guide Preventive Care Guide Kern Family Health Care wants you to get good health care. These preventive care guidelines help you stay healthy by preventing diseases or by finding them early on. Preventive care

More information

Immunization Guidelines for the Use of State Supplied Vaccine April 18, 2013

Immunization Guidelines for the Use of State Supplied Vaccine April 18, 2013 DTaP / DT DTaP/IPV/Hep B Combination (Pediarix ) Children from 6 weeks of age up to the 7 th birthday Children from 2 months of age up to the 7th birthday: Indicated for the primary doses of DTaP, IPV,

More information

Immunisation Policy. Country Children s Early Learning Ph: M:

Immunisation Policy. Country Children s Early Learning Ph: M: Immunisation Policy Published June 2018 Review Date December 2019 Sources Education and Care Services National Regulations, October 2017 Guide to the Education and Care Services National Law and the Education

More information

SPOKANE COMMUNITY COLLEGE HEALTH SCIENCE PROGRAMS 1810 N GREENE STREET, MS 2090 SPOKANE WA PHYSICAL EXAMINATION (Student completes this side)

SPOKANE COMMUNITY COLLEGE HEALTH SCIENCE PROGRAMS 1810 N GREENE STREET, MS 2090 SPOKANE WA PHYSICAL EXAMINATION (Student completes this side) SPOKANE COMMUNITY COLLEGE HEALTH SCIENCE PROGRAMS 1810 N GREENE STREET, MS 2090 SPOKANE WA 99217 PHYSICAL EXAMINATION (Student completes this side) Name: Program: Address: Date of Birth: Day Phone: Evening

More information

Daycare, school entry and school program immunization report. Data for school year 2016/17

Daycare, school entry and school program immunization report. Data for school year 2016/17 Daycare, school entry and school program immunization report Data for school year 2016/17 Table of Contents 1. Introduction... 1 2. Data Source... 1 3. Limitations... 2 4. Daycare - Proof of Immunization...

More information

Information Regarding Immunizations

Information Regarding Immunizations Information Regarding Immunizations Dear Staff Member / Volunteer The state of Massachusetts require our staff members and volunteers aged 17 and under to have and provide evidence of the following immunizations:

More information

Gardasil Network Development Project GARDASIL VACCINE QUESTIONNAIRE

Gardasil Network Development Project GARDASIL VACCINE QUESTIONNAIRE Questionnaire ID Gardasil Network Development Project GARDASIL VACCINE QUESTIONNAIRE Answering this questionnaire is voluntary. Personal identifying information will not be shared with anyone outside of

More information

Recommended Health Screenings

Recommended Health Screenings Recommended Health Screenings UnitedHealthcare appreciates the preventive care you deliver to our members. Please use the below health screening chart to schedule screenings based on the member s age and

More information

Immunization Report Public Health September 2013

Immunization Report Public Health September 2013 Immunization Report Public Health September 2013 Daycare, school entry and school program immunization enrollment rates, up to 2012 Table of Contents 1. Introduction... 2 2. Data Source... 2 3. Limitations...

More information

Community Immunization Education Guide Tool Kit

Community Immunization Education Guide Tool Kit Community Immunization Education Guide Tool Kit Contents Topic 1 Topic 2 Topic 3 Topic 4 Topic 5 Topic 6 Topic 7 Topic 8 Purpose How to Use the Five Key Messages Pre-Training Survey Overview Vaccine Preventable

More information

Choosing a Pediatrician

Choosing a Pediatrician Choosing a Pediatrician Babies and children are not just small adults--their health care needs are different. So, it is important to find a health care professional that can provide specialized care. As

More information

IMMUNIZATION & PHYSICAL FORM

IMMUNIZATION & PHYSICAL FORM Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U PLEASE UPLOAD

More information

K 6 th Express Billing Contract

K 6 th Express Billing Contract 2017-2018 K 6 th Express Billing Contract Child Information: First Middle Initial Last Parent/Guardian Information: First Middle Initial Last Address Phone Requested Start Will you be receiving state/other

More information

Preventive health guidelines As of April 2012

Preventive health guidelines As of April 2012 Preventive health guidelines As of April 2012 What is your plan for better health? Make this year your best year for wellness. Your health plan may help pay for tests to find disease early and routine

More information

Preventive health guidelines

Preventive health guidelines Preventive health guidelines As of May 2017 What is your plan for better health? Make this year your best year for wellness. Your health plan may help pay for tests to find disease early and routine wellness

More information

Required Health Records for all Students

Required Health Records for all Students Required Health Records for all Students Failure to complete all required forms and immunizations will prohibit you from registering for classes or attending clinical rotation Health Records Specialist

More information

HOWARD UNIVERSITY STUDENT HEALTH CENTER. Checklist of Immunizations/TB tests/medical History/Physical Exam

HOWARD UNIVERSITY STUDENT HEALTH CENTER. Checklist of Immunizations/TB tests/medical History/Physical Exam Checklist of Immunizations/TB tests/medical History/Physical Exam Note: this checklist must be submitted with the immunization/tb testing forms Please complete ALL of the requirements below and check off

More information

IMMUNIZATION & PHYSICAL FORM

IMMUNIZATION & PHYSICAL FORM Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U Instructions:

More information

Dear Parents/Guardians:

Dear Parents/Guardians: Dear Parents/Guardians: The Pennsylvania School Health Law requires all students to have Medical and Dental exams within one year prior to a student s entry into the grade in which an exam is required:

More information

GUYS, THIS IS YOUR WELLNESS CHECKLIST Use it to stay up to date and in the know about your health.

GUYS, THIS IS YOUR WELLNESS CHECKLIST Use it to stay up to date and in the know about your health. GUYS, THIS IS YOUR WELLNESS CHECKLIST Use it to stay up to date and in the know about your health. The top six things you can do to live a healthier life: Get recommended tests. Be tobacco-free. Be physically

More information

Immunization Guidelines For the Use of State Supplied Vaccine July 1, 2011

Immunization Guidelines For the Use of State Supplied Vaccine July 1, 2011 DTaP / DT DTaP/IPV/Hep B Combination (Pediarix ) Children from 6 weeks of age up to the 7 th birthday Children from 2 months of age up to the 7th birthday: Indicated for the primary doses of DTaP, IPV,

More information

Tennessee Immunization Program Updates

Tennessee Immunization Program Updates Tennessee Immunization Program Updates Kelly L. Moore, MD, MPH Medical Director, TN Immunization Program Tennessee Association of School Nurses Murfreesboro, Tennessee November 3, 2011 Objectives Recent

More information

Appendix An Assessment Tool to Determine the Validity of Vaccine Doses

Appendix An Assessment Tool to Determine the Validity of Vaccine Doses Appendix 4.4 - An Assessment Tool to Determine the Validity of Vaccine Doses Note: Refer to the Canadian Immunization Guide and New Brunswick (NB) immunization program directives for recommendations for

More information

Student Health Record

Student Health Record LAWRENCE MEMORIAL/REGIS COLLEGE NURSING AND RADIOGRAPHY PROGRAMS Student Health Record All three parts of this record must be complete. Health Records must be uploaded to the Castle Branch website at https://mycb.castlebranch.com

More information