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501.5.5.1.1P - Follow-up Notification of Immunization Law Requirements for Early Childhood Students

501.5.5.1.1P - Follow-up Notification of Immunization Law Requirements for Early Childhood Students

Adopted: June 2014
Revised

 

Download 501.5.5.1.1 - Follow-up Notification of Immunization Law Requirements for Early Childhood Students

 

 

         Date ______________________

Dear parent/guardian of _____________________________________,   

                                                                        print student name

 

A.     Your child must be current on all required immunizations or provide documentation of exemption in order to remain in school. We do not have a record of the following immunizations:

 

 

            DTaP

            Polio

            MMR

            Hib

          Varicella

          Pneumococal (2-24 months)

          Hepatitis A

          Hepatitis B

 

 

B.     Please complete one of the four options below and provide the appropriate documentation to the school nurse:  

 

1.    Once the immunization indicated above has been given, write the date (month, day, year) of the immunization on the Early Childhood Immunization Form located on the reverse of this document, sign where indicated, and return this document to your school nurse; or

 

2.   If your child has received at least one of a series of immunizations and will complete the series within the next eight months, the physician must indicate such and sign the Early Childhood Immunization Form located on the reverse of this document, then return the document to your school nurse; or

 

3.   If your child will not receive the immunization due to a medical contraindication or laboratory evidence of immunity, you must give the school nurse a statement signed by a physician (you may use the statement on the reverse of this document), or

 

4.   If your child will not receive the immunization due to conscientiously held beliefs, you must give the school nurse a notarized statement signed by the parent or guardian (you may use the statement on the reverse of this document).

 

C.     If you meet any one of the following Minnesota Vaccines for Children (MnVFC) eligibility criteria, you may call Dakota County Public Health (952-891-7999) to receive low-cost vaccinations (There may be no charge for the vaccine for children meeting the criteria listed below):

·        You are uninsured;

  • You are enrolled in Minnesota Medical Assistance (MA), Minnesota Care (MnCare) or Prepaid Medical Assistance Program (PMAP);

·        You are an American Indian or Alaskan Native, or

·        You have health insurance that does not cover the cost of the vaccine.

                    

D.     Submit proof of compliance with the state immunization law to the school nurse. Call the school nurse if you have any questions regarding immunizations for your child. We appreciate your timely attention to this matter. 

 

 

School District Official                                                    School Nurse ________________________________