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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 Notification of Exclusion For Missing Vaccines (Shots)Dear Parent/Guardian,Date:All children must receive the immunizations (shots) required by New York State Law Section 2164 in order to attend school. A letter from the NYS Department of Health is attached stating that this law applies whether your child attends in person, virtually, or a combination of both.You are receiving this letter because your child is missing required vaccines, the doses cannot be counted because they were given too close together, or your child was too young to receive the vaccine at the time it was given.You must provide proof of immunization(s) by ___________ or your child can no longer attend school.These are the immunizations needed: Proof of Immunization can be:3335655180975An immunization certificate signed or stamped by your health care provider.A record issued by NYSIIS or CIR from NYC or an official immunization registry from another state or official record from a foreign country.An electronic health record from your provider’s office.A blood test (titer) lab report that proves your child is immune to measles, mumps, rubella varicella (chickenpox), or hepatitis B.For varicella (chickenpox), a note from your health care provider (MD, NP, PA) which says your child had chickenpox.00An immunization certificate signed or stamped by your health care provider.A record issued by NYSIIS or CIR from NYC or an official immunization registry from another state or official record from a foreign country.An electronic health record from your provider’s office.A blood test (titer) lab report that proves your child is immune to measles, mumps, rubella varicella (chickenpox), or hepatitis B.For varicella (chickenpox), a note from your health care provider (MD, NP, PA) which says your child had 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)If you do not have a health care provider or need help getting the immunizations, we can provide information how to get them form the local health department. Sincerely, (Principal Name)______________________________________________________________________ Phone #:_____________________________________Fax:____________________________________ This sample resource is available on the New York State Center for School Health website at Samples|Forms 9/20 ................
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