PM 286 B
PM 286 B
PM 286 B
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 school and child care personnel from an immunization record provided by parent or guardian. See reverse side for instructions.
Student Name Name of Parent or Guardian Telephone Sex: M F Birthdate Address City ZIP Place of Birth
Race/Ethnicity:
White, not Hispanic Hispanic
Daytime
Nighttime
Black Other:
VACCINE
I. DOCUMENTATION
I certify that I reviewed a record of this child's immunizations and transcribed it accurately: Date Staff Signature
MMR (Measles, mumps, and rubella) HIB (Required only for child care and preschool) HEPATITIS B VARICELLA (Chickenpox) HEPATITIS A (Not required)
TB SKIN TESTS Type*
PPD-Mantoux Other PPD-Mantoux Other
Date given
Date read
mm indur
Impression
Pos Neg Pos Neg
Record Presented was: Yellow California Immunization Record Out-of-state school record Other immunization record Specify: II. STATUS OF REQUIREMENTS A. All Requirements are met. / / Date B. Currently up-to-date, but more doses are due later. Needs follow-up. Exemption was granted for: C. Medical Reasons- Permanent D. Medical Reasons- Temporary E. Personal Beliefs III. 7th GRADE ENTRY A. All Requirements are met.
Name Date
B. Currently up-to-date, but more doses are due later. Needs follow-up.
Name Date
PM 286B (1/02)
*If required for school entry, must be Mantoux unless exception granted by local health department.
CREENCIAS PERSONALES: ESTA DECLARACIN JURADA DEBE SER FIRMADA POR EL PADRE O LA MADRE O EL GUARDIN
Solicito por la presente la dispensa de mi hijo, nombrado en el reverso, de los requisitos para vacunas de la entrada a la escuela/guardera 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/guardera por su propia proteccin. Signature (Firma) Date (Fecha)
Applicable only in those jurisdictions where the Tuberculosis Assessment is required for school entry
Personal Beliefs Affidavit to be Signed by Parent or GuardianTuberculosis
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: Declaracin Jurada Debe ser Firmada por el Padre o la Madre o el Guardin
Solicito por la presente la dispensa de mi hijo, nombrado en el reverso, de los requisitos para la evaluacin de la tuberculosis (tisis) de la entrada a la escuela ya que esta evaluacin es opuesta a mis creencias. Comprendo que si hay razn 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.