To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information.
CHILD'S NAME:
ADDRESS:
All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age.
REQUIRED TESTS/EVALUATIONS:
Note to examiner: Please give the family a completed or updated yellow California Immunization Record. Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).
VACCINE:
Polio (OPV or IPV)
DATE EACH DOSE WAS GIVEN:
VACCINE:
DtaP/DPT/DT/Td (diphtheria, tetanus, and [acellular] pertussis) OR (tetanus and diphtheria only)
DATE EACH DOSE WAS GIVEN
VACCINE:
MMR (measles, mumps, and rubella)
DATE EACH DOSE WAS GIVEN:
VACCINE:
HIB MENINGITIS (Haemophilus Influenzae B) (Required for child care/preschool only)
DATE EACH DOSE WAS GIVEN:
VACCINE:
HEPATITIS B
DATE EACH DOSE WAS GIVEN:
VACCINE:
VARICELLA (Chickenpox)
DATE EACH DOSE WAS GIVEN:
I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Health Examiner's Information
Your information will be encrypted.