NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF COMMUNICABLE DISEASE CONTROL IMMUNIZATION PROGRAM

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1 NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF COMMUNICABLE DISEASE CONTROL IMMUNIZATION PROGRAM Dear Parent: This is a reminder that certain vaccinations are required for your child to attend school. Please see your doctor or health care provider to obtain the necessary documentation of your child s vaccination status. Students will need to receive a second dose of measles vaccine if they have not already had two doses. The second dose of measles can be given at the same time as your child s polio and DTP (or DT) booster at your regularly scheduled doctor s office visit. The State Department of Health recommends that the second dose of measles be given in the form of MMR (measles-mumps-rubella) vaccine in order to provide complete protection against all three vaccine-preventable diseases. There is no danger in giving these vaccines to a child who has received them in the past. The following vaccines are required for your child to attend school: 3 doses of diphtheria containing toxoid (usually administered as DTP, DT or Td) 3 doses of oral poliovirus vaccine (OPV) or enhanced inactivated poliovirus vaccine (EIPV) 1 dose of Tdap vaccine as per New York State Immunization Chart 1 dose of mumps vaccine administered after 12 months of age 1 dose of rubella vaccine administered after 12 months of age 2 doses of measles vaccine, the first administered after 12 months of age and the second after 15 months of age 3 doses of Hepatitis B for children born on or after 1/1/93 1 dose of varicella vaccine for children born on or after 1/1/00 3 doses of Haemophilus influenzae type b (Hib) conjugate vaccine for all children less than five years of age who are enrolled in a day care, pre-kindergarten or nursery school. For a child who is 15 months of age or older, it is acceptable to have received a single dose of Haemophilus influenzae type b Conjugate Vaccine at or after the age of 15 months. (Pre-school children only.) NYS PUBLIC HEALTH LAW ARTICLE 13. TITLE 10. SECTION A STATES THAT: Prior to or within 30 days of initial enrollment, schools are required to obtain from the child s parent or guardian, proof that the child has had a blood lead test for children born on or after January The child s cumulative health record must indicate either the date of the lead screening or that information on lead poisoning referral was provided. In some instances doctor-verified disease histories (for mumps and measles) are acceptable as evidence of immunity. Blood tests which show immunity against measles, mumps or rubella are also acceptable as proof of immunity. Religious or medical exemptions to these requirements must be submitted to school officials in writing. If you have any questions, you can call your school nurse, local health department or the State Immunization Program s regional representative in Albany at (518) We wish your child a happy, productive and healthy academic career.

2 New York State Immunization Requirements for School Entrance/Attendance 1 Vaccines Pre kindergarten School (k 12) (day care, nursery, Head Start, or pre k) 2 Diphtheria Toxoid Containing Vaccine 3 doses (New York City Schools 4 doses) 3 3 doses (New York City schools 4 doses required for kindergarten only) Tetanus Toxoid Containing Vaccine and 3 doses if born on or after 1/1/2005 Not applicable until student born on or Pertussis Vaccine (DTaP, DTP) 4 after 1/1/2005 enrolls in school Tetanus, Diphtheria, and Pertussis Booster (Tdap) Not applicable Born on or after 1/1/94 and enrolling in 6th and 7th grades for the school year 5 1 dose Polio (IPV or OPV) 3 doses 3 doses Measles, Mumps and Rubella (MMR) 6 1 dose 2 doses of measles containing vaccine and 1 dose each of mumps and rubella (preferably as MMR) Hepatitis B 3 doses 3 doses 7 Haemophilus influenzae type b (Hib) 3 doses if less than 15 months of age or Not applicable 1 dose administered on or after 15 months of age 8 Pneumococcal Conjugate Vaccine (PCV) Born on or after 1/1/08 Not applicable 4 doses by 15 months of age, given at age appropriate times and intervals 9 Varicella (Chickenpox) 6 Born on or after 1/1/2000 Born on or after 1/1/98 or born on or after 1/1/94 and enrolling in grades 6 through 9 for the school year 10 1 dose Rev. 9/08

3 1 Demonstrated serologic evidence of either measles, mumps, rubella, hepatitis B or varicella antibodies is acceptable proof of immunity to these diseases. Diagnosis by a physician, physician assistant or nurse practitioner that a child/student has had measles, mumps, or varicella diseases is acceptable proof of immunity to those diseases. 2 Children in a Pre kindergarten setting should be age appropriately immunized. The number of doses depends on the schedule recommended by the Advisory Committee on Immunization Practices (ACIP). 3 Please note at this time that New York State requires 3 doses of diphtheria toxoid containing vaccine (New York City requires 4 doses for pre kindergarten and kindergarten only) and three doses of polio vaccine for entry into kindergarten and for any student entering a school in New York State for the first time. However, ACIP recommends 4 doses of diphtheria toxoid containing vaccine by age 18 months and 5 doses by age 4 6 years of age. Children 4 6 years of age should receive 4 doses of polio vaccine unless the 3rd dose is given after 4 years of age. 4 DTaP is the vaccine currently recommended for diphtheria, tetanus and pertussis. 5 Students enrolling in the 6th and 7th grades includes students who are entering, repeating or transferring into the 6th and 7th grades and students who are enrolling in gradeless classes and are the age equivalent of 6th and 7th grades. Ten year olds entering 6th and 7th grades do not need to have a Tdap vaccine. They will need to receive a Tdap once they turn 11. Students who receive a Td vaccine within 2 years prior to entering 6th and 7th grades should not receive (with rare exceptions) the booster dose of Tdap until 2 years has elapsed. It is required that those students who are not eligible on this basis be flagged, tracked, and immunized at the appropriate time. 6 The New York State Department of Health Immunization Program concurs with the ACIP which recommends that vaccine doses administered up to 4 days before the minimum interval or 12 months of age for measles, mumps, rubella and varicella be counted as valid. 7 Hepatitis B For students in grades 7 12, 3 doses of Recombivax HB or Engerix B is required, except for those students who received 2 doses of adult hepatitis B vaccine (Recombivax) which is recommended for children years old. 8 Four doses of Haemophilus influenzae type b (Hib) is recommended by 15 months or more of age, however only 3 doses are required for day care entry. If a child enters a day care on or after 15 months of age, and has not received 3 doses of Hib vaccine, only one dose on or after 15 months of age is required. 9 Unvaccinated children 7 11 months of age should receive 2 doses, at least 4 weeks apart, followed by a 3rd dose at age months. Unvaccinated children months of age should receive 2 doses of vaccine at least 8 weeks apart. Previously unvaccinated children months of age should receive only 1 dose. 10 Students enrolling in grades 6 through 9 includes students who are entering, repeating or transferring into grades 6 through 9 and students who are enrolling in gradeless classes and are the age equivalent of grades 6 through 9. Two (2) doses of varicella vaccine are recommended for all students, but not required for school entry. For further information contact: New York State Department of Health, Bureau of Communicable Disease Control Immunization Program, Rm 649 Corning Tower ESP, Albany, NY (518) New York City Department of Health and Mental Hygiene, Bureau of Immunization, Program Support Unit, P.O. Box 21, 18th Floor/Mailroom, 2 Layfayette St., New York, NY (212) New York State Department of Health/Bureau of Communicable Disease Control/Immunization Program Rev. 9/08

4 Name: Port Jefferson School District 350 Old Post Rd, Port Jefferson, NY NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and triennially for the Committee on Special Education (CSE). of Birth: HEALTH CERTIFICATE / APPRAISAL FORM School: Gender: M F Grade: IMMUNIZATIONS / HEALTH HISTORY Immunization record attached Sickle Cell Screen: Positive Negative Not done : No immunizations given today PPD: Positive Negative Not done : Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done : Dental Referral Yes No Not done : Significant Medical/Surgical History: See attached Allergies: LIFE THREATENING Food: Insect: Other: Seasonal Medication: PHYSICAL EXAM of Exam: Urine Results: Sugar: Protein: Height: _ Weight: Blood Pressure: _ Pulse: Body Mass Index:. Vision - without glasses/contact lenses R L Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L less than 5 th 5 th through 49 th 50 th through 84 th Vision - Near Point R L 85 th through 94 th 95 th through 98 th 99 th and higher Hearing Pass 20 db sc both ears or: R L Tanner: I. II. III. IV. V. Scoliosis: Negative Positive: EXAM ENTIRELY NORMAL Specify any abnormality (use reverse of form if needed): MEDICATIONS Medications (list all): None Additional medications listed on reverse of form Name: Name: Dosage/Time: Dosage/Time: If AM dose is missed at home: I assess this student to be self-directed Yes No Student may self carry and self administer medication Yes No Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if the morning medication has not been given. PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked: Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball. Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump. Specify medical accommodations needed for school: None Known or suspected disability: Please monitor Restrictions: Please monitor Provider s Signature: Phone: (Stamp below) Provider s Name/Address: Parent Signature: Fax: : This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school medical director. Rev. 2/08

5 Port Jefferson School District Certificate of Immunization Edna Louise Spear Elementary School Port Jefferson Middle School Earl L. Vandermeulen High School 500 Scraggy Hill Road 350 Old Post Road 350 Old Post Road Port Jefferson, N.Y Port Jefferson, N.Y Port Jefferson, N.Y NAME OF PUPIL DATE OF BIRTH ADDRESS OF PUPIL SEX M / F TEACHER SCHOOL GRADE Section 2164 of the Public Health Law revised September 1989, requires that all children entering or attending school be immunized against Diphtheria, Polio, Measles, German Measles (Rubella), Mumps and Hib. The school is mandated to have written certification on file, therefore, we request that you have your doctor complete this form and return it to the school. Diphtheria, Pertussis, Tetanus (DPT) s: 1. _ 2. _ 3. _ Booster Diphtheria/Tetanus (DT) : _ Tdap : Measles/Mumps/Rubella (MMR)(Live after one year of age) : 2 nd dose (Recommended between 4 & 6 yrs) : Trivalent Polio (Oral) s: 1. _ 2. _ 3. _ Booster Tuberculin Month _ Year Result Haemophilus (Hib) (18 months 5 years) s: Hepatitis B (Hep B) s: Varicella Vaccine Month _ Year _ Lead Screening (Children born on or after January 01) Month Year Physician s Signature Name: Address: (Please Print) g:\pkk\registration\immunization

6 Port Jefferson School District Immunization Acknowledgement Edna Louise Spear Elementary School Port Jefferson Middle School Earl L. Vandermeulen High School 500 Scraggy Hill Road 350 Old Post Road 350 Old Post Road Port Jefferson, N.Y Port Jefferson, N.Y Port Jefferson, N.Y (631) (631) (631) Dear Parent/Guardian: New York State Education Law and the Regulations of the Commissioner of Education require a physical examination of all children who enter a school district for the first time. It must be completed no more than 12 months prior to, or 30 days after entering school. New York State Public Health Law, Section 2164, mandates that schools cannot permit a child to be admitted unless the parent provides the school with a certificate of immunization or proof from a physician that the child is in the process of receiving the required immunizations. Attached are school forms for your convenience. According to law, these must be completed within 14 days of the child s entry to school. Please complete and sign the enclosed health forms, as well as the acknowledgement below. If you should have any questions or specific health concerns, feel free to call the appropriate school. Parent/Guardian Acknowledgement Student Name Grade Phone Pursuant to Public Health Law 2164, I/we the undersigned acknowledge that we have fourteen (14) days (30 days for records from out of NY State) to provide the Port Jefferson School District with our son s/daughter s immunization records. Furthermore, we understand that failure to comply within the allotted time may result in my child s exclusion from school. Parent s/guardian s Signature

7 Port Jefferson School District Health History Edna Louise Spear Elementary School Port Jefferson Middle School Earl L. Vandermeulen High School 500 Scraggy Hill Road 350 Old Post Road 350 Old Post Road Port Jefferson, N.Y Port Jefferson, N.Y Port Jefferson, N.Y Dear Parent: Please fill out this form for Health Services and return with all registration materials. Please print legibly. Complete immunization records must be attached. Name of Pupil M F Grade Entering Address Telephone of Birth Birthplace Name of Father Address Name of Mother Address Guardian (if other than above) _ Address Native Language Spoken at Home Family Physician: Name Telephone # Address Previous School: Address: Is there a History of: Asthma Chicken Pox Diabetes Ear Conditions Epilepsy Heart Disease Measles Mumps Nephritis Pneumonia Rheumatic Fever Scarlet Fever Tuberculosis or (TB Contact) Allergies (Please Specify) Other Has your child had any operations, serious illness, injuries? Please give dates and explain: Does your child wear glasses? Contacts? Hearing Aid? of last dental exam Are there any other physical conditions which might need special attention in school? Please explain: Does your child take medication regularly? Name of medication Signature of Parent/Guardian g:\pkk\reistration\healhist.wpd

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