Form Pm 286b - California School Immunization Record
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1
2CALIFORNIA 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
Name of Parent or Guardian
Race/Ethnicity:
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
(Diphtheria, tetanus and
Staff
DTP/DTaP/DT/Td
Signature
[acellular] pertussis OR
tetanus and diphtheria only)
Record Presented was:
MMR
Yellow California Immunization Record
(Measles, mumps, and rubella)
Out-of-state school record
Other immunization record
HIB
Specify:
(Required only for child care and preschool)
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.
VARICELLA
(Chickenpox)
Exemption was granted for:
C. Medical Reasons- — Permanent
D. Medical Reasons- — Temporary
HEPATITIS A
(Not required)
E. Personal Beliefs
III. 7th GRADE ENTRY
A. All Requirements are met.
CHEST X-RAY (Necessary if skin test positive)
TB
Type*
Date given
Date read
Impression
mm indur
SKIN
PPD-Mantoux
Pos
Name
Date
TESTS
Other
Neg
Film date:
Impression:
normal
abnormal
B. Currently up-to-date, but more doses
PPD-Mantoux
Pos
are due later. Needs follow-up.
Other
Neg
Person is free of communicable tuberculosis:
yes
no
Name
Date
*If required for school entry, must be Mantoux unless exception granted by local health department.
STATE OF CALIFORNIA—DEPARTMENT OF HEALTH SERVICES
PM 286B (1/02)
IMMUNIZATION BRANCH
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