Immunization Screening and Referral Form for Kindergarten-12
Student Name: Date of Birth:
School Name: Date of Notice:
Contact Person at School:_______________________________________ Phone Number:
In accordance with Arizona State Law, students must have proof of all required immunizations in order to attend school.
Lack of proper documentation may result in your child being excluded from school until such documentation is provided to
your school health office. Your child’s immunization record with the below missing immunization(s) must be submitted:
1. If your child has already received the necessary immunization(s), bring his or her immunization record to the school. The record must show
the child’s name, date of birth, the date that all doses were received, and the name of the physician or health agency who administered the
2. If your child has not
received the necessary immunizations, take your child’s immunization record and this form to your physician,
local health department, or other vaccine provider to get required immunization(s) and/or records. Then bring this form and the
updated record back to school.
School Staff: Please Circle or Highlight the Missing Required Dose(s) for the Corresponding Required Vaccine(s).
School Required Vaccine Dose Missing
DTaP/DTP/DT (Diphtheria, Tetanus, Pertussis)
Tdap (Tetanus, Diphtheria, Pertussis)
MMR (Measles, Mumps, Rubella)
CDC Recommended Vaccine**
HPV (Human Papillomavirus)
• * Indicates that a second dose is highly recommended by the CDC but not required for school attendance.
• ** CDC: Center for Disease Control and Prevention through the Advisory Committee on Immunization Practices (ACIP) recommends routine
vaccinations to prevent vaccine-preventable diseases. While most vaccinations are required by the State of Arizona for school entry, there are other
recommended immunizations your child may need.
• ˟ Exceptions exist for these particular doses- see the Arizona school immunizations requirements for details and
Our records show that your child has not received all immunizations required for school
attendance by Arizona State Law (Arizona Revised Statutes §15-872). The immunization doses
required now are circled or highlighted.
ADHS-Arizona Immunization Program Office: (602)-364-3630 Revised Sept. 2018