FMSex: Birthdate
Student Name
Place of Birth
Race/Ethnicity:
Name of Parent or Guardian
Address
White, not Hispanic
Hispanic
Telephone ZIPCity
NighttimeDaytime
Black
Other:
DATE EACH DOSE WAS GIVEN
VACCINE
5th4th3rd2nd1st
POLIO (OPV or IPV)
(Diphtheria, tetanus and
[acellular] pertussis OR
tetanus and diphtheria only)
DTP/DTaP/DT/Td
MMR (Measles, mumps, and rubella)
HIB (Required only for child care and preschool)
HEPATITIS B
VARICELLA (Chickenpox)
HEPATITIS A (Not required)
CDPH 286 (1/14)
I. DOCUMENTATION
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
Booster
III. 7th GRADE ENTRY
A. All Requirements are met.
DateName
Date
Name
B. Currently up-to-date, but more doses
are due later. Needs follow-up.
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.
CALIFORNIA SCHOOL IMMUNIZATION RECORD
STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH
IMMUNIZATION BRANCH
Impressionmm indur Date read Date givenType*TB
SKIN
Pos
PPD-Mantoux
NegOther
TESTS
Pos
PPD-Mantoux
NegOther
*If required for school entry, must be Mantoux unless exception granted by local health department.
CHEST X-RAY (Necessary if skin test positive)
abnormalnormalImpression:Film date:
noyesPerson is free of communicable tuberculosis:
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...
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