State of California—Health and Human Services Agency Pre-kindergarten facility and school staff must record the required vaccine dose information and status of requirements for each pupil Pre-kindergarten (child care or preschool );
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State of California—Health and Human Services Agency Pre-kindergarten facility and school staff must record the required vaccine dose information and status of requirements for each pupil Pre-kindergarten (child care or preschool );
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California Pre-Kindergarten and School Immunization Record
Staff must record the required vaccine dose information and status of requirements for each pupil. See reverse side for guidance.
CDPH 286 (11/22) Pupil Name (Last,
First, Middle): Statewide Student Identifier (SSID): Ethnicity:Hispanic/LatinoNon-Hispanic/Non-LatinoRace: African American/BlackAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderWhiteOtherName of Parent/Guardian (Last,
First): Birthdate (Month/Day/Year): Sex: Required Vaccine Date Each Dose Was Given (MM/DD/YY) Permanent Medical Exemption Notes for School Requirements 1
ST 2 ND 3 RD 4 TH 5TH IPV / OPV (Polio) Age: ____ yrs. 4 doses meet TK/K-12 requirement, as do: 3 doses, if ш1 dose given at age ш4 years. DTaP / DTP ʹ Age 0-6 years Tdap / Td ʹ Age 7+ years (Diphtheria, Tetanus, Pertussis) Age: ____ yrs. Age: ____ yrs. 5 doses meet
TK/K-12 requirement, as do: 4 doses, if ш1 dose given at age ш4 years; 3 doses, if ш1 Tdap dose at age ш7 years; Tdap dose may meet 7th Grade requirement. MMR (Measles, Mumps, Rubella) Age: ____ mo. 2 doses meet TK/K-12 requirement.
Doses must be given at age ш1 year. Hib (Haemophilus influenzae type b)Required for pre-kindergarten only.
At least 1 dose must be given at age ш1 year. Hep B (Hepatitis B)3 doses meet TK/Kʹ12 requirement. VAR / VZV (Varicella/Chickenpox) 2 doses meet TK/Kʹ12 requirement. Tdap ʹ 7th Grade (Tetanus, Diphtheria, Pertussis) Age: ____ yrs.
1 dose given at age ш7 years meets requirement for 7
th grade advancement and 7 Vaccine Doses Requires Follow-up Follow-up Date(s) (See conditional admission schedule or exemption end) Other See codes on reverse side Date RequirementsMet Temporary
Medical Exemption Missing Doses
Pre-Kindergarten
(Child Care or Preschool) IEPTK/K-12IEPINDHome7
th Grade (Advancement or Admission) IEP INDHomeThe California Department of Public Health places strict controls on the gathering and use of personally identifiable data. Personal information is not disclosed, made available, or
otherwise used for purposes other than those specified at the time of collection, except with consent or as authorized by law or regulation. The Department's information management practices are consistent with the Information Practices Act (Civil Code Section 1798 et seq.), the Public Records Act (Government Code Section 6250 et seq.), Government Code Sections 11015.5 and 11019.9, and with other applicable laws pertaining to information privacy.
CDPH 286 (11/22) Guidance For Completing Form CDPH 286Pre-kindergarten (child care or preschool);
Transitional kindergarten/kindergarten through 12th grade (TK/K-12); (Or advancement to) 7th grade. (SSID) is a 10-digit number assigned to TK/K-12 public school pupils by theCalifornia Department of Education.
immunization record provided by a parent or guardian, prior school, or an immunization registry. a. Record the date (month/day/year) of each dose the pupil has received, even if the pupil has an exemption to one or more required vaccines. Any vaccine given four or fewer days prior to the minimum required age is valid.b. Check the Permanent Medical Exemption (PME) box(es) for vaccines that are permanently exempt for medical reasons. If all vaccines are exempted,
the Status of Requirements section. This date is usually the date records b. If the pupil meets admission requirements, check the designated box and date records are determined to be complete. c. If the pupil does not have all required doses but is not due for any doses at