CDPH 286 Form – Fill Out and Use This PDF

CALIFORNIA SCHOOLIMMUNIZATION RECORD

This record is part of the student's permanent record (cumulative folder) as defined in Section 49068 of the Education Code

and shall transfer with that record. Local health departments shall have access to this record in schools, child care facilities, and family day care homes.

This record must be completed by schoolandchildcare personnel from an immunization record

provided by parent or guardian. See reverse side for instructions.

Student Name

Sex:

M

F

Birthdate

Place of Birth

Race/Ethnicity:

Name of Parent or Guardian

White, not Hispanic

Address

Hispanic

Telephone

Black

City

ZIP

Daytime

Nighttime

Other:

DATE EACH DOSE WAS GIVEN

I. DOCUMENTATION

VACCINE

1st

2nd

3rd

4th

5th

Booster

I certify that I reviewed a record of this

child's immunizations and transcribed it

POLIO (OPV or IPV)

accurately:

Date

Staff

(Diphtheria, tetanus and

DTP/DTaP/DT/Td

[acellular] pertussis OR

Signature

tetanus and diphtheria only)

Record Presented was:

MMR (Measles, mumps, and rubella)

Yellow California Immunization Record

Out-of-state school record

Other immunization record

HIB (Required only for child care and preschool)

Specify:

II. STATUS OF REQUIREMENTS

A. All Requirements are met.

HEPATITIS B

Date

B. Currently up-to-date, but more doses

VARICELLA (Chickenpox)

are due later. Needs follow-up.

Exemption was granted for:

C. Medical Reasons—Permanent

HEPATITIS A (Not required)

D. Medical Reasons—Temporary

E. Personal Beliefs

III. 7th GRADE ENTRY

TB

Type*

Date given

Date read

mm indur

Impression

CHEST X-RAY (Necessary if skin test positive)

A. All Requirements are met.

SKIN

PPD-Mantoux

Pos

Name

Date

TESTS

Other

Neg

Film date:

Impression: normal

abnormal

B. Currently up-to-date, but more doses

PPD-Mantoux

Pos

Person is free of communicable tuberculosis: yes

no

are due later. Needs follow-up.

Other

Neg

*If required for school entry, must be Mantoux unless exception granted by local health department.

Name

Date

	STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH
		CDPH 286 (1/14)
	IMMUNIZATION BRANCH

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 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, in month/xx/year; however, if either measles, rubella or mumps (or MMR) was received in the month of the 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 speci 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 present documentation consistent with Health and Safety Code Section 120365, including documentation of all other required immunizations the child has received. All requirements are met; check box A and box E.*

Applicable only in those jurisdictions where the Tuberculosis Assessment is required for school entry

Personal Beliefs Afto 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 identi in case of disease outbreak in the community.