Required Immunizations For Admission To Wisconsin Schools printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

Wis. Stat. § 252.04

F-44001 (Rev. 07/2016)

LEGAL NOTICE

Required Immunizations (shots) for Admission to Wisconsin Schools

To the Parent, Guardian or Legal Custodian of ____________________________Grade ______

The Student Immunization Law requires that all students through grade 12 meet a minimum number of required

immunizations prior to school entrance. These requirements can be waived only for health, religious or personal

conviction reasons. According to our records, your child is not compliant because an immunization record is not

available at school or an immunization(s) is needed (see reason for noncompliance marked below) and there is no

waiver on file. To remain compliant with the law, please provide the month, day, and year that your child received

the required immunization(s) on the attached Student Immunization Record, or select one of the waiver options prior

to [enter 30

school day] and return the form to your child's school. Failure to do so may result in exclusion from

school, court action, and/or forfeiture penalty. If you have any questions about this notice or how to obtain the

required immunizations, please contact your child’s school.

Reason for noncompliance:

No Record

According to our school records, the following vaccines are needed:

1,2

DTaP/DT/Td

Polio

MMR

Hepatitis B

Varicella

Tdap

Dose

If your child has laboratory test results proving that your child is immune to measles and mumps and rubella, or has

laboratory test results proving that your child is immune to hepatitis B, or has laboratory test results proving that your

child is immune to varicella, provide the test results to the school. If the test results are acceptable, then your child

does not need to be vaccinated for the disease(s) to which he/she is already immune.

If your child already had chickenpox disease, varicella vaccine is not required. Answer “yes” to the chickenpox

disease question on the attached Student Immunization Record and enter the date of disease, if known.

If your child received a dose of a tetanus-containing vaccine, such as Td, within five years of entering the grade in

which Tdap is required, your child is compliant and a dose of Tdap is not required.

Your immediate cooperation is appreciated.

School

Phone

School Official (Title)

Date sent

enc: Student Immunization Record

Required Immunizations For Admission To Wisconsin Schools