Adopted: January 2004
Revised: June 2014
Gacaliye waalidka/wakiilka _____________________________________, Taariikhda ______________________
Ku qor magaca ardayga
Si an uga ahaano hab waafaqsan sharciga gobolka, ilmahaagu u baahan yahay dhammaan tallaalada hadda looga baahan yahay ama aad keento waraaqo ka mid ah dhaafitaanka tallaalka si uu u jooga dugsiga. Annagu ka maxayno diiwaan ee:
2nd MMR (Measles, Mumps and Rubella) immunization 2nd HepB (Hepatitis B) immunization
2nd Varicella (Chicken Pox) immunization 3rd HepB (Hepatitis B) immunization
3-dose series of HepB (Hepatitis B) vaccine Polio (IPV, OPV) immunization
Tdap (Tetanus, Diphtheria and Pertussis) or Meningococcal immunization
Td (Tetanus, Diphtheria) booster
Sida looga baahan yahay sharciga gobolka ee ilmahaaga, Haddii diiwaanka tallaalo/tallaal ilmahaaga ama caddayn dhaafitaan aan la helin xafiiska kalkaalisada caafimaadka ee dugsiga _ taariikhaha ku qoron hoose ee warqaddan, ilmahaaga ma la oggolaan doono inay dugsiga dhigtaan ilaa shuruudaha sharciga la waafajiyo.
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Waxaa jira siyaabo dhawr ah oo aad addeecid kartid sharciga:
1. Marka tallaalka kor lagu tilmaamay la siiyo, ku qor taariikhda (bisha, maalinta, sannadka) ee foomka tallaalka Ardayda ku yaala bogga dambe ee dokumentigaan, saxiix meesha la tilmaamay, oo ku soo celi dokumentigaan kalkaalisada caafimaadka ee dugsiga, ama
2. Haddii ilmahaagu helay ugu yaraan mid ka mid ah taxane oo tallaalada iyo dhameystiri doona taxane sideedii bilood ee soo socda gudahood, dhakhtarka waa in uu soo saxiixo foomka Tallaalka ardayda ku yaala bogga dambe ee dokumentigaan, dabadeedna ku soo celi dukumeentiga kalkaalisada dugsiga, ama
3. Haddii ilmahaagu heli donin tallaalka sabab u ah calaamad muujinaysa ama shaybaarka caddayn xasaanad caafimaad, waa in aad kalkaalisada dugsiga la siiyo warbixin uu ku saxiixaan dhakhtarka (waxaad isticmaali kartaa qoraal ku saabsan bogga dambe ee dokumentigaan), ama
4. Haddii ilmahaagu heli doonin tallaalka sabab u ah aaminsan ogsoon la qabtaa, waa in aad kalkaalisada dugsiga la siiyo war qoraal ah oo nootaayo la saxiixay waalidka ama masuulka (waxaad isticmaali kartaa qoraal ku saabsan booga dambe ee dokumentigaan).
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Haddii aad la kulanto mid ka mid ah Minnesota ka Tallaalada soo socda ee shuruudaha Carruurta (MnVFC), waxaad wici kartaa Waaxda Caafimaadka Guud ee Degmada Dakota (952-891-7999) si aad u hesho talaalada oo qiimo-jaban (Waxaa laga yaabaa in aad ku hesho lacag la'aan tallaalka carruurta shuruudaha hoos ku qoran):
· Waxaad tahay aan caymiska lahayn;
· Waxaad ku qoran tahay Medical Assistance Minnesota (MA), Minnesota Care (MNCare) ama Barnaamijka Prepaid Medical Assistance (PMAP);
· Waxaad tahay Hindida ama Alaska Native American ah, ama
· Waxaad leedahay caymis caafimaad oo aan dabooli karin kharashka tallaalka.
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Sida laga soo xigtay Minnesota Statute 121A.15 (sharciga tallaalka carruurta dugsiga), ilmahaagu loo ogolaan doonin in ay dugsiga dhigtaan haddii kalkaalisada caafimaadka ee dugsiga aysan heleen mid ka mid ah xujooyinka waafaqsan ee kor ku xusan (Taariikhda 30 maalmood- Kalandarka) iyo/ama
Taariikhda Tallaalka
(8 bilood taariikhda dhammaystirka taxanaha tallaalka) .
Taariikhda Tallaalka
Waxaan aad ugu mahadnaqaynaa in arrinta muhiimka ah aad ku sameyso waqtiga ku habboon. Haddii aad qabto wax su'aalo ah, fadlan soo wac kalkaalisada dugsiga.
Si Daacadnimo,
Maamulaha_______________________Kalkaalisada Dugsiga______________________________