New York State Center for School Health / Homepage
Notification of Exclusion Based on Immunization StatusDear Parent/Guardian,Date:We have not received proof that your child has received the immunizations (shots) required by New York State Law Section 2164, to enter and attend school. Unless you provide proof of immunization by ____________ your child can no longer attend school.Proof of immunization can be:An immunization certificate signed or stamped by your health care practitionerA record issued by NYSIIS or CIR from NYC or an official immunization registry from another state or official record from a foreign countryAn electronic health record from your provider’s officeA blood test (titer) lab report that proves your child is immune to the diseasesFor varicella (chickenpox), a note from your health care provider (MD, NP, PA) which says your child had chickenpox.If you do not have a health care provider or need help getting the immunizations, we can provide information from the local health department where your child can receive them.Your child needs these immunizations to attend schoolImmunizationNumber of Doses NeededDiphtheria/Tetanus/Pertussis (DTaP or Tdap)PolioMeasles/Mumps/Rubella (MMR)Hepatitis BVaricella (Chickenpox)Meningococcal Conjugate (MenACWY)Hemophilus Influenzae (HIB)Pneumococcal Conjugate (PCV)Sincerely,(Principal Name)Phone #: Fax: Email: ................
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