F 04020L Form PDF Details

In compliance with state law, all public and private school students in Wisconsin are required to present written evidence of immunization against certain diseases within thirty school days of admission. The F 04020L form, a crucial component in the Wisconsin Department of Health Services’ efforts to monitor and ensure public health safety within schools, serves as the official document for this purpose. Parents, guardians, or legal custodians are tasked with completing this form, which includes providing personal data of the student, an immunization history detailing dates of vaccinations against diseases such as Diphtheria, Tetanus, Pertussis, Polio, Hepatitis B, MMR (Measles, Mumps, Rubella), and Varicella (Chickenpox), and compliance data to affirm whether the student meets the current school year’s immunization requirements. The form also provides options for filing health, religious, or personal conviction waivers against the immunization requirement. Importantly, it outlines potential exclusion from school for incompletely immunized students in the event of an outbreak and the legal implications of failing to adhere to the vaccination schedule. The form, thus, plays a vital role not just in ensuring individual compliance but in safeguarding public health by preventing the spread of vaccine-preventable diseases within the educational setting.

QuestionAnswer
Form NameF 04020L Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names04020l form, kentucky immunization form 2018, Record, vaccine records ky

Form Preview Example

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

252.04 and 120.12 (16) Wis. Stats.

F-04020L (Rev. 07/12)

 

STUDENT IMMUNIZATION RECORD

INSTRUCTIONS TO PARENT: COMPLETE AND RETURN TO SCHOOL WITHIN 30 DAYS AFTER ADMISSION. State law requires all public and private school students to present written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific requirements are available from schools and local health departments. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed with the school. The purpose of this form is to measure compliance with the law and will be used for that reason only. If you have questions on immunizations or how to complete this form, contact your child’s school or local health department.

 

PERSONAL DATA

PLEASE PRINT

 

 

 

 

 

Step 1

Student’s Name

Birthdate

(Mo/Day/Yr)

Gender

School

Grade

School Year

 

 

 

 

 

 

 

 

 

Name of Parent/Guardian/Legal Custodian

Address

(Street, City, State, Zip)

Telephone Number

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

IMMUNIZATION HISTORY

Step 2

List the MONTH, DAY AND YEAR your child received each of the following immunizations. DO NOT USE A (√) OR (X) except to answer the

 

question about chickenpox, Tdap or Td. If you do not have an immunization record for this student at home, contact your doctor or public health

 

department to obtain it.

 

 

 

 

 

 

 

TYPE OF VACCINE*

FIRST DOSE

SECOND DOSE

 

THIRD DOSE

FOURTH DOSE

FIFTH DOSE

 

 

 

Mo/Day/Yr

Mo/Day/Yr

 

Mo/Day/Yr

Mo/Day/Yr

Mo/Day/Yr

 

DTaP/DTP/DT/Td (Diphtheria, Tetanus, Pertussis)

 

 

 

 

 

 

 

Adolescent booster

(Check appropriate box)

 

 

 

 

 

 

 

Tdap

Td

 

 

 

 

 

 

 

Polio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (Measles, Mumps, Rubella)

 

 

 

 

 

 

 

Varicella (Chickenpox) Vaccine

 

 

 

 

 

 

 

Vaccine is required only if your child has not had

 

 

 

 

 

 

 

chickenpox disease. See below:

 

 

 

 

 

 

 

Has your child had Varicella (chickenpox) disease? Check the appropriate box

 

 

 

 

 

And provide the year if known:

 

 

 

 

 

 

 

YES ____________________ year (Vaccine not required)

 

 

 

 

 

 

NO or Unsure (Vaccine required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 3

Step 4

Step 5

REQUIREMENTS

Refer to the age/grade level requirements for the current school year to determine if this student meets the requirements.

COMPLIANCE DATA

STUDENT MEETS ALL REQUIREMENTS

Sign at Step 5 and return this form to school.

Or

STUDENT DOES NOT MEET ALL REQUIREMENTS

Check the appropriate box below, sign at Step 5, and return this form to school. PLEASE NOTE THAT INCOMPLETEY IMMUNIZED STUDENTS MAY BE EXCLUDED FROM SCHOOL IF AN OUTBREAK OF ONE OF THESE DISEASES OCCURS.

Although my child has NOT received ALL required doses of vaccine, the FIRST DOSE(S) has/have been received. I understand that the SECOND DOSE(S) must be received by the 90th school day after admission to school this year, and that the THIRD DOSE(S) and FOURTH DOSE(S) if required must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in writing each time my child receives a dose of required vaccine.

NOTE: Failure to stay on schedule and notify the school may result in court action and a fine of up to $25.00 per day of violation.

WAIVERS (List in Step 2 above, the date(s) of any immunizations your child has already received)

For health reasons this student should not receive the following immunizations

______________________________________________

______________________________________________________________

______________________________________________

SIGNATURE - Physician

Date Signed

For religious reasons this student should not be immunized.

 

For personal conviction reasons this student should not be immunized.

 

____________________________________________________________________________________________________________________

LIST VACCINE(S) WAIVED

SIGNATURE

This form is complete and accurate to the best of my knowledge. Check one: ( I do

I do not

) give permission to share my child’s current

immunization records and as they are updated in the future with the Wisconsin Immunization Registry (WIR). I understand that I may revoke this consent at any time by sending written notification to the school district. Following the date of revocation, the school district will provide no new records or updates to the WIR.

___________________________________________________________________

____________________________________________

SIGNATURE - Parent/Guardian/Legal Custodian or Adult Student

Date Signed

 

 

How to Edit F 04020L Form Online for Free

varicella can be completed online with ease. Simply open FormsPal PDF editing tool to complete the job quickly. FormsPal team is committed to providing you with the best possible experience with our editor by regularly presenting new functions and improvements. Our editor is now much more useful with the latest updates! At this point, working with PDF forms is easier and faster than ever. This is what you'll need to do to get going:

Step 1: Just click on the "Get Form Button" in the top section of this page to launch our pdf editing tool. Here you will find all that is necessary to fill out your file.

Step 2: Using our state-of-the-art PDF file editor, you're able to accomplish more than just fill in blank form fields. Express yourself and make your forms appear great with custom textual content added in, or optimize the file's original input to perfection - all comes along with the capability to insert almost any pictures and sign it off.

It really is an easy task to complete the form using this detailed tutorial! Here's what you should do:

1. The varicella requires certain details to be inserted. Be sure that the subsequent blank fields are finalized:

04020l form completion process described (part 1)

2. The next step would be to submit these particular blank fields: STUDENT DOES NOT MEET ALL, Although my child has NOT received, SECOND DOSES must be received by, NOTE Failure to stay on schedule, For health reasons this student, SIGNATURE Physician Date Signed, For religious reasons this student, For personal conviction reasons, LIST VACCINES WAIVED SIGNATURE, Step This form is complete and, give permission to share my, and I do not.

04020l form conclusion process shown (portion 2)

People who work with this document frequently make some mistakes when filling out I do not in this section. Remember to reread whatever you type in here.

Step 3: Revise the information you have inserted in the blank fields and then hit the "Done" button. Acquire the varicella when you sign up at FormsPal for a free trial. Easily access the document within your personal account page, with any edits and adjustments automatically preserved! FormsPal is dedicated to the privacy of all our users; we make sure that all information coming through our tool continues to be secure.

F 04020L Form isn’t the one you’re looking for?

Related Documents