Fillable Form H.2.4 - Incomplete Immunizations, Registration printable pdf download

INCOMPLETE IMMUNIZATIONS, REGISTRATION _______

H-2-4Revised AUG. 2012

Office of the School Nurse

DATE: ____________________

MEMORANDUM FOR: Parents/Sponsor of ____________________________________________________________

SUBJECT: Incomplete Immunizations

1. DoDEA Manual 2942.0, March 2004 states that PRIOR to enrollment in DoDEA schools, students shall meet

specific immunization requirements.

2. The following immunizations are missing from your child’s records:

_____ Diphtheria/Tetanus/Pertussis: after fourth birthday or dose # _____

_____ Hepatitis A: dose #1_____ #2_____

_____ Hepatitis B: dose #1_____ #2_____#3_____

_____ Measles/Mumps/Rubella: dose #1 _____ #2_____

_____ Meningococcal Conjugate Vaccine: dose # 1_____ (at age 11 years)

dose # 2_____ (at age 16 years)

_____ Polio Vaccine after the fourth birthday or dose # _____

_____ Tetanus/Diphtheria/Pertussis Booster (at age 11 years old)

_____ Varicella (Chicken Pox): _____ reliable history or dose # 1_____ # 2_____

_____ Other: ______________________________________________________________________________

_____ A copy of your child's up-to-date immunization record.

3. Tuberculosis Testing: The frequency of PPD (TB) testing is directed by the local medical authority. A PPD is

required every ____ years in this community. Annual TB questionnaire missing: _____

PPD due: _________________________ PPD results needed: _________________________

4. Annual Influenza vaccination requirement is determined by local medical authority. If required in your

community, proof of vaccination is to be presented to school officials NLT 30 days after the local medical

authority notifies school administration that the vaccine is available.

Date available: _________________________

5. As of July 2010, DoDEA adopted the Interstate Compact on Educational Opportunity for Military Children. The

compact language reads that “compacting states shall give thirty (30) calendar days from the date of enrollment

for students to obtain any immunization(s) required by the receiving state. For a series of immunizations, initial

vaccinations must be obtained within thirty (30) days.”

6. Please take this form, your child’s outpatient medical record, and/or immunization record with you to your child’s

appointment. Bring your child’s up-to-date immunization record to school as soon as possible so that enrollment

requirements for your child are complete. Your child’s registration will be complete when requested

documentation of required immunizations is received by school officials.

7. Bring your child's updated immunization record to school as soon as possible, but no later than

___________________________________.

8. If you have any questions, please call

___________________________________

Form H.2.4 - Incomplete Immunizations, Registration