F 04020L Form PDF Details

The F 04020L form is a French tax form that is used to report income and capital gains. This form must be filed by all taxpayers in France who earn income or profits from capital gains. The deadline for filing this form is May 15th of the following year. There are a number of details that must be included on this form, so it is important to be familiar with the requirements before you begin filing. If you need help completing the F 04020L form, there are many resources available online and in print. Make sure to file your return on time to avoid penalties and interest charges.

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

 

 

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04020l form completion process described (part 1)

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