1. No category

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 reportinghelp@shotsforschool.org.
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.