California School Immunization Record

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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
Telephone
City
ZIP
Daytime
Nighttime
Black
Other:
DATE EACH DOSE WAS GIVEN
I. DOCUMENTATION
VACCINE
1st
2nd
3rd
4th
5th
Booster
I certify that I reviewed a record of this
child’s immunizations and transcribed it
accurately:
POLIO (OPV or IPV)
Date
Staff
(Diphtheria, tetanus and [acellular]
DTP/DTaP/DT/Td
Signature
pertussis
OR tetanus and diphtheria only)
Record presented was:
Yellow California Imm. Record
MMR
(Measles, mumps, and rubella)
Out-of-state school record
Other immunization record
(Required only for child care and preschool)
Specify:
HIB MENINGITIS
(Haemophilus B)
II. STATUS OF REQUIREMENTS
A. All requirements are met.
HEPATITIS B
Date
B. Currently up-to-date, but more doses
are due later. Needs follow-up.
Exemption was granted for:
VARICELLA
(Chickenpox)
C. Medical Reasons—Permanent
D. Medical Reasons—Temporary
TB
Type*
Date given
Date read
Impression
mm indur
E. Personal Beliefs
SKIN
PPD-Mantoux
Pos
III. 7th GRADE ENTRY
TESTS
Other
Neg
A. All requirements are met.
PPD-Mantoux
Pos
Other
Neg
Name
Date
*If required for school entry, must be Mantoux unless exception granted by local health department.
B. Currently up-to-date, but more doses
are due later. Needs follow-up.
CHEST X-RAY
Film date:
Impression:
normal
abnormal
(Necessary if
Name
Date
Person free of communicable tuberculosis:
yes
no
skin test positive.)
PM 286B (3/01)
STATE OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES
IMMUNIZATION BRANCH

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