CDPH 286 (1/19)
GUIDANCE FOR COMPLETING FORM CDPH 286
Review the pupil’s immunization record for admission to:
• Pre-kindergarten (child care or preschool);
• Transitional kindergarten/kindergarten through 12
th
grade (TK/K-12);
• (Or advancement to) 7
th
grade.
1. Complete the pupil’s identification section. The Statewide Student Identifier
(SSID) is a 10-digit number assigned to TK/K-12 public school pupils by the
California Department of Education.
2. Complete the vaccine and dose section using information from the pupil’s
immunization record provided by a parent or guardian, prior school, or an
immunization registry.
a. Record the date (month/day/year) of each dose the pupil has received,
even if the pupil has an exemption to one or more required vaccines.
Any vaccine given four or fewer days prior to the minimum required age
is valid.
b. Check the Permanent Medical Exemption (PME) box(es) for vaccines
that are permanently exempt for medical reasons. If all vaccines are
exempted, then fill in the date for “Date Requirements Met” in the
appropriate row in the Status of Requirements section. This date is
usually the date records are determined to be complete. File the
required physician’s written statement specifying the exempted
immunization(s) in the pupil’s record.
3. Complete the appropriate row in the Status of Requirements section.
a. Enter the initials of the staff reviewing the pupil’s record.
b. If the pupil meets admission requirements, check the designated box
and enter the date under “Date Requirements Met.” This date is usually
the date records are determined to be complete.
c. If the pupil does not have all required doses but is not due for any
doses at the time of admission, check the “Missing Doses Not Currently
Due–Conditional” box and fill in the “Follow-up Date(s)” space. Review
records at least every 30 days. Once the pupil meets all admission
requirements, fill in the date for “Date Requirements Met.”
d. If the pupil has a Temporary Medical Exemption, check the designated
box and write the expiration date in the “Follow-up Date(s)” space.
Once the pupil meets all admission requirements, fill in the date for the
“Date Requirements Met.”
e. If the pupil is due for doses and subject to exclusion, check the
“Missing Doses Are Overdue–Needs Doses Now” box and fill in the
“Follow-up Date(s)” space.
f. If the pupil does not have all required immunizations and does not meet
criteria for conditional admission (including a temporary medical exemption)
and is:
• IEP: Accessing special education services required by the pupil’s
individualized education program, or
• IND: Enrolled in an independent study program and does not receive
classroom-based instruction, or
• Home: Enrolled in a ho
me-based private school, or
• PBE (pre-2016): Transferring from another school in California with a
valid personal beliefs exemption filed before 2016,
Then, using the codes above, check the appropriate box under “Other” and
fill in the date for “Date Requirements Met.”
Maintain a roster of all pupils who are unimmunized for immediate
identification in case of disease outbreak or exposure in the community.
TRANSFER PUPILS
Transferring from a school in-state or another state: Review the
immunization information and supporting documentation for exemptions
included in the pupil’s record or other immunization record, verifying the pupil
has met immunization requirements for the pupil’s age/grade. If the pupil has a
personal beliefs exemption (PBE) filed in California prior to 2016 and has not
reached the next grade span (in accordance with Health and Safety Code
section 120335) or has a Permanent Medical Exemption (PME), then add the
pupil’s name to your facility’s roster of unimmunized pupils.
Transferring from your school: Provide this form or an equivalent
immunization record as specified in 17 CCR section 6070(b) and any
exemption documentation as part of the pupil’s record.
If a pupil transfers from one school to another within California, the pupil’s
record shall be transferred by the former school no later than 10 school days
following the date of request from the school where the pupil intends to enroll
(California Education Code section 49068).
Foster children: California law requires schools to immediately enroll foster
children transferring to their school even if the child is unable to produce
immunization records normally required for school entry. Within two business
days of the foster child's request for enrollment, the educational liaison for the
new school shall contact the school last attended to obtain all records. The
educational liaison for the school last attended shall provide all records to the
new school within two business days of receiving the request (California
Education Code section 48853.5(e)(8)(C)).
