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Note to School Administrators Regarding Immunization ExclusionThe following items should be shared with parents/guardians who will be notified of student exclusion due to the lack of documentation of required immunizations. Whenever possible, this information should be provided in the parent/guardian’s primary language.This may be accomplished utilizing outside resources such as the NYS Department of Health (NYSDOH) website, the Center for Disease Control and Prevention (CDC) website, and /or interpreters.A verbal explanation and a written copy of the school policyWritten documentation specifying the immunization(s) their child is missingInformation on where to obtain the missing immunization(s)This sample resource was created by the New York State Center for School Health. It is located at – Samples|Forms 9/20School District LetterheadSample 2020 - 2021 Exclusion Notification of Missing Immunizations (Shots) During COVID-19 Dear Parent/Guardian,Date:All children must receive the immunizations (shots) required by New York State Public Health Law Section 2164 to attend school. The Department of Health Memo (11/10/20) states this applies to all students when attending school in-person, remote learning, or both (Hybrid model).You are receiving this letter because your child is missing immunizations, or the doses cannot be counted because they were given at the wrong time. If you do not have a doctor (health care provider) or need help getting the immunizations, we can give you information on how to get them from the local health department.Your child needs: Proof of Immunization can be:333375095250Immunization certificate signed or stamped by your health care provider.Official immunization registry from New York State, New York City, another state or official record from a foreign country.Electronic health record copy from your health care provider’s office.Blood test (titer) lab report that proves your child is immune to measles, mumps, rubella; varicella (chickenpox); or hepatitis B.A note from a health care provider (doctor, nurse practitioner, or physician assistant) which says your child had varicella (chickenpox).00Immunization certificate signed or stamped by your health care provider.Official immunization registry from New York State, New York City, another state or official record from a foreign country.Electronic health record copy from your health care provider’s office.Blood test (titer) lab report that proves your child is immune to measles, mumps, rubella; varicella (chickenpox); or hepatitis B.A note from a health care provider (doctor, nurse practitioner, or physician assistant) which says your child had varicella (chickenpox).Immunization Name# of Doses NeededDiphtheria/Tetanus/Pertussis (DTaP or Tdap)PolioMeasles/Mumps/Rubella (MMR)Hepatitis BVaricella (Chickenpox)Meningococcal Conjugate (MenACWY)Hemophilus Influenzae (HIB)Pneumococcal Conjugate (PCV)Proof of immunization must be given to school by 12/11/20 for your child to be able to continue remote learning. The school is required by law to exclude (not allow to attend) remote learning students who do not have proof of immunizations beginning 12/12/20.Parent/Guardian Compliance Agreement (Affidavit)For students who are attending school remotely we must have a signed statement from you as required by the Department of Health. This will allow your child to continue to attend remote learning while waiting to get the immunization(s) by December 11.I agree to have my child get the needed immunizations. I agree to keep the immunization follow-up appointments as scheduled. If my health care provider (HCP) has to change the schedule due to my child’s illness, I will provide a written note from the HCP to the school with a new appointment date. ________________________________ ____________________________________ ____/____/_____ Parent/Guardian Name (Print) Parent/Guardian Signature Date ___________________________________________________ ___________________________ _____/_____/________School Official Signature Phone DateThis sample resource is available on the NYS Center for School Health website Samples|Forms 11/17/20 ................
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