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U4248002 Paula 6-1-00
INSTRUCTIONS FOR SCHOOL OR CHILD CARE STAFF
1. Complete child’s name and address information section, or ask parent or guardian to complete this section only. (This form is not to be sent home or given to
parents to complete.)
2. School or child care personnel then fill in date (month/day/year) of each immunization the student has received from the Immunization Record presented by
the parent or guardian. (If the date consists only of month and year for some doses, fill in month/xx/year; however, if either measles, rubella or mumps (or
MMR) was received in the month of the first birthday, month/day/year is required.)
3. Determine if immunization requirements have been met, using the California ‘‘Immunization Requirements for Grades K–12,’’ or ‘‘Immunization Requirements
for Child Care,’’ (available from Immunization Coordinators in local health departments), or other requirements guide.
4. Complete the Documentation and Status of Requirements box.
A. Fill in date and your signature as the staff member who reviewed and transcribed the immunization record presented by the parent or guardian. Check
which type of record was presented.
B. If the child has met all immunization requirements, check box A and write in date.
C. If the child has not met all requirements, check box B. Child can be admitted only if up-to-date, e.g., no immunizations due currently. The child must be
followed up as indicated in the ‘‘Guide to Immunization Requirements.’’
D. If a child is to be exempted for medical reasons, a doctor’s written statement is required; the statement must include which immunization(s) is to be exempted
and the specific nature and probable duration of the medical condition. If the medical exemption is permanent, the requirement for the designated
immunization(s) is met: check box A and box C.* If the medical exemption is temporary, check box B and box D; this child must be followed up.*
E. If a child is to be exempted for reasons of personal beliefs, the parent or guardian must sign and date the affidavit below. No other parents should sign this
affidavit. All requirements are met; check box A and box E.*
PERSONAL BELIEFS AFFIDAVIT TO BE SIGNED BY PARENT OR GUARDIAN—IMMUNIZATION
I hereby request exemption of the child, named on the front, from the immunization requirements for school/child care entry because all or some immunizations are contrary
to my beliefs. I understand that in case of an outbreak of any one of these diseases, the child may be temporarily excluded from attending for his/her protection.
CREENCIAS PERSONALES: ESTA DECLARACIÓN JURADA DEBE SER FIRMADA POR EL PADRE O LA MADRE O EL GUARDIÁN
Solicito por la presente la dispensa de mi hijo, nombrado en el reverso, de los requisitos para vacunas de la entrada a la escuela/guardería ya que algunas o todas de las
vacunas son opuestas a mis creencias. Comprendo que en caso de un brote en la communidad de alguna de estas enfermedades, mi hijo puede ser excluido temporalmente
de la escuela/guardería por su propia protección.
Date (Fecha)Signature (Firma)
Applicable only in those jurisdictions where the Tuberculosis Assessment is required for school entry
Personal Beliefs Affidavit to be Signed by Parent or Guardian—Tuberculosis
I hereby request exemption of the child named on the front from the tuberculosis assessment requirement for school/child care center entry because this procedure(s) is contrary to my beliefs.
I understand that should there be cause to believe that my child is infected with active tuberculosis or should there be a tuberculosis outbreak, my child may be temporarily excluded from school.
Creencias Personales: Declaración Jurada Debe ser Firmada por el Padre o la Madre o el Guardián
Solicito por la presente la dispensa de mi hijo, nombrado en el reverso, de los requisitos para la evaluación de la tuberculosis (tisis) de la entrada a la escuela ya que esta evaluación es opuesta a mis
creencias. Comprendo que si hay razón para sospechar que mi hijo sufra de la tuberculosis activa o si hay un brote de la tuberculosis, mi hijo puede ser excluido de la escuela.
Signature (Firma) Date (Fecha)
* Names of all children who are exempt should be maintained on an exempt roster for immediate identification in case of disease outbreak in the community.
