Reports due October 15, 2014 Oc October 15, 2013 HOW TO COMPLETE THE KINDERGARTEN IMMUNIZATION ASSESSMENT STEP 1: Download/Access the Kindergarten Worksheet and the Kindergarten Immunization Requirements:     Kindergarten Immunization Assessment Worksheet (PM236A) Guide to Immunizations Required for School Entry, Grades K-12 California School Immunization Record (Blue Card, PM-286) �New’ PBE Form (CDPH-8262) These are available for download at: www.shotsforschool.org/reporting To order more Blue Cards, contact your local health department. Some facilities have electronic systems and may not need the worksheet. Note:      Report immunization status of ALL kindergarten students (traditional AND transitional) as of the date the report is completed. For ungraded classes, report on entering students from age 4 years-9 months to age 5 years-9 months. Do not report on pre-K students or after-care enrollees. Submit one report for each school campus per year. If a student has an exemption and is also a conditional entrant, please report the student as having an exemption only. If a student has a permanent medical exemption and a personal beliefs exemption, report the student as having received a personal beliefs exemption only. STEP 2: Determine Number of Doses Received by Vaccine Type for Each Student and Enter into the Worksheet: Enter each child's name or other identifier on the “WORK SHEET” provided (PM 236A). Then determine the immunization status of each child (see process below) by reviewing each student's blue California School Immunization Record (CSIR, PM-286), which must be included in the student's cumulative file. Be sure these forms are up-to-date before proceeding. A. An "Unconditional Entrant" is a student who: 1. MEETS all kindergarten immunization requirements by having: Number of Vaccine Doses Required Doses Req. if 1 dose after 4 yrs. of age: Polio 4 3 DTP/DT 5 4 Measles—containing vaccine ( at least 1 dose of MMR) 2 Hepatitis B 3 Varicella (or physician-documented varicella disease) 1 1 OR: 2. Presents a physician's statement of PERMANENT Medical Exemption (PME) for any doses that have not been received; OR: 3. Presents a valid Personal Beliefs Exemption (PBE):  For entry before January 1, 2014: A signed statement of personal beliefs on the back of CA School Immunization Record OR  For entry on or after January 1, 2014: A completed �new’ PBE Form ( �Personal Beliefs Exemption to Required Immunizations’, CDPH-8262) For each student, check the appropriate box on the Kindergarten Worksheet: 1. All Immuns. OR 2. PME If student is PBE, check only one of the following:  a. Pre-Jan 2014 column - if a 2nd year transitional kindergartener with a personal beliefs exemption taken prior to January 1, 2014.  b. Health Care Practitioner column - if there is documentation of counseling from an authorized health care practitioner in section A of the �new’ PBE Form (CDPH 8262) or its equivalent  c. Religious column - if the parent had indicated a religious personal beliefs exemption in Section B of the �new’ PBE Form or its equivalent Examples - “Unconditional Entrants” Section of Kindergarten Worksheet Unconditional Entrants The child has: Student Status 1. All Imms. All required imms PME PBE – �pre Jan’ PBE –�HP-counseled’ PBE – �Religious’ B. 2. PME Type of PBE: 3. PBE (3a+3b+3c) 3a. Pre-Jan 3b. Health pract 3c. Religious 2014 -Counseled X X X X X A "Conditional Entrant" is a student who DOES NOT meet the immunization requirements because: 1. they are �in process’ and have no received all required doses, 2. they have a temporary medical exemption, or 3. they are transfer student and have yet to receive their immunization documentation �Conditional entrants’ must be followed up to ensure they become fully-vaccinated. For these students, check the 4. Cond. box on the Worksheet AND check mark the box for each vaccine (a. Polio, b. DTP, c. MMR, d. Hepatitis B, e. Varicella) for which the child is missing doses. Example – �Conditional Entrants” Section of Kindergarten Worksheet Student Status Missing Hep B, DTP Transfer – no record Temp PME – no MMR Missing 1 DTP 4. Cond. X X X X a. Polio X Conditional Entrants - Dose not meet requirements for: b. DTP c. MMR d. Hepatitis B X X X X X X X e. Varicella X 2 Before reporting, review the worksheet for errors. Check that each �Unconditional Entrant’ has a single check mark in either Column 1, 2, 3a, 3b, or 3c. In addition, all �Conditionals Entrants’ must have a check mark in Column 4 plus one or more checkmarks in 4a, 4b, 4c, 4d, and 4e. No students should ever have a check mark under both “Unconditional Entrants” and “Conditional Entrants”. STEP 3: Login to the Kindergarten Reporting Site: a. Go to www.shotsforschool.org. b. Click on the Child Care/School Reporting tab on the left side of the main page. c. Click on the Kindergarten link to open the Kindergarten Reporting page. STEP 4: Completing & Submitting Your Report Online: Reports due October 15, 2014 Oc October 15, 2013 a. Login: Choose from the drop down menus: School Type, County, District (if public), School Name and School Address. Then enter the Password: school and click the Log in button. Alternatively, enter your sevendigit school code (the last seven digits of your CountyDistrict-School (CDS) code in the School Code box, then enter the password: school. b. Confirm Kindergarten Status:  If your school does not have kindergarten students enrolled this year, respond No to the question, “Do you have kindergarten students enrolled this year?” and choose a reason from the drop down box. Then answer whether your students are schooled at home and whether your school is an online/virtual school. Then select Confirm and continue at the bottom to proceed.  If your school does have kindergarten students enrolled this year, respond Yes to the question. Then answer whether your students are schooled at home and whether your school is an online/virtual school. Then select Confirm and continue at the bottom to proceed. 3      c. Complete the Report: Enter the total Number of Kindergarten Students Enrolled. Transfer the Totals from the worksheet into the corresponding spaces on the report.* Double check that the numbers are correct: Row 3, “Personal Beliefs Exemption to any immunizations” will autosum based on 3a+3b+3. Row 1, 2, 3, and 4 must TOTAL EXACTLY the “Number of K Students Enrolled” and row 4 must be accounted for by spaces 4a, 4b, 4c, 4d, and/or 4e. *If you are using Internet Explorer 10, you may need to click in the box to enter information instead of using tab. d. Submitting Your Report:  Include your contact information as the report submitter and enter a designated school contact.  Review your information for accuracy and then select Submit.  All reports must be submitted on or before October 15th. 4  Print/Save a copy for your records by selecting Print Report or Download Report (PDF). Retain your worksheet for your records.  If you will be reporting for another school, select Logout to return to the login page and repeat steps 1-4. Congratulations, you have completed the report online. 5 Kindergarten & 7th Grade Immunization Assessment Frequently Asked Questions 1. Q: What is my login password? A: For Kindergarten: school For 7th Grade: shots 2. Q: I cannot find my School Name after selecting appropriate School Type (public or private) and District (only if public). What should I do? A: If your school is new, and it isn’t yet listed, you’re not required to report this year. If your school isn’t new, please contact the CA Department of Education to confirm your school has the correct grade span, enrollment and status. You may but are not required to submit a paper form which you can obtain from your local health department. 3. Q: How do I print or download a copy for my records? A: After you Submit the report, select Print Report or Download Report (PDF) before logging out. If you’ve already logged out, view or print these instructions from the Login Page: Need to Confirm We Received Your Submission or Print a Copy for Your Records? K | 7 4. Q: How can I be sure you received my submission? A: View or print these instructions from the Login Page: Need to Confirm We Received Your Submission or Print a Copy for Your Records? K | 7 5. Q: I already submitted my report but now realize I made a mistake. How can I correct the error(s) if I have already submitted the report? A: Once you re-login, select �Revise your Submitted Report’. Make your changes, then click �Submit’ to save and submit your revised report. Changes can be made up until reporting closes. 6. Q: How can I send a copy of this form to my district office? A: Make copy or download as described in Question 4 and send to District office. 7. I do not have internet capability. How can I complete this form? A: Please contact your local health department (see Help section below) to request hard copy materials. 8. I have a student who is conditional for one vaccine and has an exemption. How do I report? A: Report the student as having an exemption only. 9. I have a student who is has a permanent medical exemption for one vaccine and a personal beliefs exemption for another. How do I report? A: Report the student as having a personal beliefs exemption. FAQs Regarding Transitional or Junior Kindergarten 8. Q: Are students in the transitional or junior kindergarten also subject to the kindergarten immunization requirements? A: Yes. Every child age 4-6 years old in kindergarten must meet the Kindergarten requirements or have a valid exemption prior to admission to Kindergarten. 9. Q: How should a school report these transitional or junior kindergarten students for the kindergarten annual immunization assessment report? A: Record the status of every child in your Kindergarten on the form - the reporting process does not distinguish transitional and traditional kindergarten students. _____________________________________________________________________________________________ HELP If you need further assistance, please contact your local health department listed on the next page. Rev. 09/14 Local Health Department Phone Numbers Do you need more California School Immunization Records (Blue CSIR Cards) or have any questions? Contact your local health department at the number listed below. County (Website Link) Phone County (Website Link) Phone County (Website Link) Phone Alameda 510-267-3230 Madera 559-675-7893 San Luis Obispo 805-781-5500 Alpine 530-694-2146 Marin 415-473-3078 San Mateo 650-573-2877 Amador 209-223-6407 Mariposa 209-966-3689 Santa Barbara 805-346-8420 Berkeley City 510-981-5300 Mendocino 707-472-2600 Santa Clara 408-937-2271 Butte 530-538-7581 Merced 209-381-1023 Santa Cruz 831-454-4645 Calaveras 209-754-6460 Modoc 530-233-6311 Shasta 800-971-1999 Colusa 530-458-0380 Mono 760-924-1830 Sierra 530-993-6705 Contra Costa 925-313-6767 Monterey 831-755-4683 Siskiyou 530-841-2134 Del Norte 707-464-3191 Napa 707-253-4270 Solano 707-784-8001 El Dorado 530-621-6100 Nevada 530-265-1450 Sonoma 707-565-4567 Fresno 559-600-3550 Orange 714-834-8560 Stanislaus 209-558-4817 Glenn 530-934-6588 Pasadena City 626-744-6000 Sutter 530-822-7215 Humboldt 707- 268-2108 Placer 530-889-7141 Tehama 530-527-6824 Imperial 760-482-4438 Plumas 530-283-6330 Trinity 530-623-8218 Inyo 760-873-7868 Riverside 951-358-7125 Tulare 800-834-7121 Kern 661-321-3000 Sacramento 916-875-7468 Tuolumne 209-533-7401 Kings 559-852-2579 San Benito 831-637-5367 Ventura 805-981-5211 Lake 707-263-1090 San Bernardino 800-722-4794 Yolo 530-666-8645 Lassen 530-251-8183 San Diego 866-358-2966 Yuba 530-749-6366 Long Beach City 562-570-4315 San Francisco 415-554-2830 Los Angeles 213-351-7800 San Joaquin 209-468-3481 Rev 07/14 GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY Grades K-12 INSTRUCTIONS Use this guide as a quick reference to help you determine whether children seeking admission to your school meet California’s school immunization requirements. For the actual laws, see Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075. If you have any questions, call the Immunization Coordinator at your local health department. IMMUNIZATION REQUIREMENTS To enter into public and private elementary and secondary schools (grades kindergarten through 12, including transitional kindergarten), children under age 18 years must have immunizations. VACCINE REQUIRED DOSES Polio 4 doses at any age, but... 3 doses meet requirement for ages 4–6 years if at least one was given on or after the 4th birthday1; 3 doses meet requirement for ages 7–17 years if at least one was given on or after the 2nd birthday.1 Diphtheria, Tetanus, and Pertussis Age 6 years and under: DTP, DTaP or any combination of DTP or DTaP with DT (diphtheria and tetanus) 5 doses at any age, but... 4 doses meet requirements for ages 4–6 years if at least one was on or after the 4th birthday.1 Age 7 years and older: Tdap, Td, or DTP, DTaP or any combination of these 4 doses at any age, but...3 doses meet requirement for ages 7–17 years if at least one was on or after the 2nd birthday.1 If last dose was given before the 2nd birthday, one more (Tdap) dose is required. Measles, Mumps, Rubella (MMR) Age 4-6 years (kindergarten and above): 2 doses2 both on or after 1st birthday.1 7th grade: 2 doses2 both on or after 1st birthday.1 Age 7-17 years and not entering or advancing into 7th grade: 1 dose on or after 1st birthday.1 Hepatitis B3 Age 4-6 years (kindergarten and above): 3 doses. Varicella 1 dose4, 6 Tdap Booster (Tetanus, reduced diphtheria, and pertussis) 7th grade: 1 dose on or after 7th birthday. 5, 7 Receipt of a dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement. Two doses of measles-containing vaccine required. One dose of mumps and rubella-containing vaccine required; mumps vaccine is not required for children 7 years of age and older. 3 Not required for 7th grade. 4 Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement. 5 Tdap, DTaP, or DTP given on or after 7th birthday will meet the requirement. Td does not meet the requirement. 6 2 dose varicella requirement for ages 13-17 years applies to transfer students who were not admitted to a California school before July 1, 2001. 7 8th-12th grade students transferring from outside of California must meet the requirement. 1 2 EXEMPTIONS The law allows parents/guardians to submit an exemption from immunization requirements based on their personal beliefs or medical conditions. For children with medical exemptions, the physician’s written statement should be submitted. Schools should maintain an up-to-date list of pupils with exemptions, so they can be excluded quickly if an outbreak occurs. For more information, visit shotsforschool.org NOT MEETING REQUIREMENTS Refer pupils who do not meet these State requirements to their physician or local health department. Give families a written notice indicating which doses are lacking. CONDITIONAL ADMISSIONS Children who lack one or more required vaccine doses that are not currently due may be admitted on condition that they receive the remaining doses when due (Title 17, CCR Section 6035). IMM-231 (4/14) California Department of Public Health • Immunization Branch • ShotsForSchool.org State of California—Health and Human Services Agency California Department of Public Health KINDERGARTEN IMMUNIZATION ASSESSMENT WORK SHEET (Do Not Send In) Each child should have either one check mark under column 1, 2 or 3 (and if a check under 3, then also a check under column 3a, 3b, or 3c) or a check mark under column 4 (and if a check under 4, then also check marks under columns 4a, 4b, 4c, 4d, and/or 4e) never under both headings. (Use the K-12 Guide to Immunizations Required for School Entry to determine status.) NOTE: The numbers and letters on these columns coincide with those on the SCHOOL SUMMARY SHEET. UNCONDITIONAL ENTRANTS CONDITIONAL ENTRANTS NAME OR ID — the child has: Type of PBE: —does not meet requirement for: 1.All Imms 2. PME1 a. Pre-Jan 3. PBE (3a+3b+3c) 2 20143 b. Health Pract. c. Religious5 4. Cond.6 a. Polio b. DTP c. MMR d. Hep B e. Varicella7 Counseled4 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Subtotal this page (count check marks) Gr and Total all pages 1 COPY TO SCHOOL SUMMARY SHEET 1. 2. 3. 3a. 3b. 3c. 4. 4a. 4b. 4c. 4d. 4e. 1. 2. 3. 3a. 3b. 3c. 4. 4a. 4b. 4c. 4d. 4e. Permanent medical exemption (PME) to some or all immunizations 2 Personal beliefs exemption (PBE) to some or all immunizations; each child with a PBE should have only one type of PBE checked. The grand total of all check marks in column 3 must equal the grand total of all check marks in column 3a+3b+3c. 3 PBE to some or all immunizations taken before January 1, 2014 (i.e., parent or guardian signed affidavit on back of CSIR) 4 Health Care Practitioner Counseled PBE to some or all immunizations taken on or after January 1, 2014; documentation of counseling from an authorized health care practitioner in section A of CDPH 8262 or its equivalent 5 Religious PBE to some or all immunizations taken on or after January 1, 2014; the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262 6 Lacks one or more required immunizations 7 A conditional entrant for varicella is a child who has neither received the varicella vaccine nor has health care provider-documented varicella disease or immunity. PM 236A (7/14) Page 1 of 2 UNCONDITIONAL ENTRANTS NAME OR ID — the child has: 1.All Imms 2. PME1 Type of PBE: a. Pre-Jan 3. PBE (3a+3b+3c) CONDITIONAL ENTRANTS 2 2014 3 b. Health Pract. Counseled —does not meet requirement for: c. Religious5 4. Cond.6 a. Polio b. DTP c. MMR d. Hep B e. Varicella7 4 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. Subtotal this page (count check marks) 1. Gr and Total all pages COPY TO SCHOOL SUMMARY SHEET 1. 2. 3. 3a. 3b. 3c. 4. 4a. 4b. 4c. 4d. 4e. 2. 3. 3a. 3b. 3c. 4. 4a. 4b. 4c. 4d. 4e. 1 Permanent medical exemption (PME) to some or all immunizations Personal beliefs exemption (PBE) to some or all immunizations; each child with a PBE should have only one type of PBE checked. The Grand Total of all check marks in column 3 must equal the grand total of all check marks in column 3a+3b+3c. 3 PBE to some or all immunizations taken before January 1, 2014 (i.e., parent or guardian signed affidavit on back of CSIR) 4 Health Care Practitioner Counseled PBE to some or all immunizations taken on or after January 1, 2014; documentation of counseling from an authorized health care practitioner in section A of CDPH 8262 or its equivalent 5 Religious PBE to some or all immunizations taken on or after January 1, 2014; the parent had indicated a religious personal beliefs exemption in Section B of CDPH 8262 6 Lacks one or more required immunizations 7 A conditional entrant for varicella is a child who has neither received the varicella vaccine nor has health care provider-documented varicella disease or immunity. 2 PM 236A (7/14) Page 2 of 2 CALIFORNIA SCHOOL IMMUNIZATION 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 school and child care 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 Address White, not Hispanic Hispanic Black Telephone Daytime City Other: Nighttime DATE EACH DOSE WAS GIVEN VACCINE POLIO (OPV or IPV) (Diphtheria, tetanus and [acellular] pertussis OR tetanus and diphtheria only) 2nd 3rd 4th 5th / / / / / / / / / / / / / / / / 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* Date given Date read mm indur Impression PPD-Mantoux Other / / / / Pos Neg PPD-Mantoux Other / / / / Pos Neg *If required for school entry, must be Mantoux unless exception granted by local health department. STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC HEALTH IMMUNIZATION BRANCH I. DOCUMENTATION 1st / / DTP/DTaP/DT/Td ZIP Booster / / CHEST X-RAY (Necessary if skin test positive) Film date: / / Impression: normal Person is free of communicable tuberculosis: yes abnormal no I certify that I reviewed a record of this child's immunizations and transcribed it accurately: Date / / / / Staff Signature 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 Name Date B. Currently up-to-date, but more doses are due later. Needs follow-up. CDPH 286 (01/14) 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 fill 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, fill in month/xx/year; however, if either measles, rubella or mumps (or MMR) was received in the month of the first 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 specific 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 Affidavit to 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 identification in case of disease outbreak in the community.
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