Notice Of Immunizations Needed
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1NOTICE OF IMMUNIZATIONS NEEDED
Dear Parent/Guardian of: ___________________________________________________
Our records show that your child needs the following immunization(s) to meet the requirements
of the California School Immunization Law, Health and Safety Code Sections 120325-120375:
VACCINE
MISSING DOSE(S) MARKED BELOW:
POLIO
#1
#2
#3
#4
DTaP
#1
#2
#3
#4
#5
(Tdap or Td if age 7 years or older.)
MMR
#1
#2
Hib (child care/preschool only)
#1
#2
#3
#4
HEPATITIS B
#1
#2
#3
VARICELLA (chickenpox)
#1
#2
th
th
Tdap (for 7
– 12
grade)
#1
YOU NEED TO DO ONE OR MORE OF THE FOLLOWING IMMEDIATELY:
1. If your child has already received all of these immunizations marked above, bring us the
immunization record so that we can update our files. Your child’s record must include a
date for the immunizations checked above and the doctor’s signature or stamp.
2.
If your child hasn’t already received all of the immunizations marked above, bring this
form along with your child’s immunization record to your doctor or local health
department to get the immunization(s) marked above. Bring us your child’s updated
.
immunization record after every immunization visit until all of the required immuniza-
tions have been received.
3. If any of these immunizations were not given to your child because of medical reasons,
please bring us a letter from your doctor (licensed physician).
.
According to state law, we cannot allow your child to attend school unless we receive
evidence that the above requirements are met by this date:___________________
For more information on school immunization requirements, visit
If you have any questions or require additional information, please call___________________.
Sincerely,
IMM-1140 (12-15)
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