Dublin City School District
Immunization Requirements – K-12
Students
5320 F1
Page 1 of 2
Revised 4/9/13
English
To the Parent of: ___________________________________________________
D.O.B. ______________________
From: ____________________________________________________________
Date: ________________________
FOR THE 2013-2014 SCHOOL YEAR, OHIO LAW REQUIRES ALL STUDENTS HAVE A MINIMUM OF THE
IMMUNIZATIONS LISTED BELOW TO ATTEND SCHOOL. A RECORD OF THESE IMMUNIZATIONS MUST BE ON
FILE WITH THE SCHOOL BY THE 14TH DAY THE STUDENT ATTENDS SCHOOL OR THE STUDENT WILL BE
EXCLUDED.
FALL 2013
IMMUNIZATIONS FOR CHILD CARE, HEAD START AND PRE-SCHOOL
ATTENDANCE
VACCINES
DTaP/DTP/DTTdap/Td
Diphtheria,
Tetanus,
Pertussis
POLIO
MMR
Measles, Mumps, Rubella
Kindergarten
Four (4) or more doses of DTaP or DT, or any combination. If the fourth dose is properly spaced and
administration after the 4th birthday, a 5th dose is not required.
Grades 1-12
Four (4) or more doses of DTaP or Td, or any combination. Three doses of Td or a combination of Td and
Tdap is the minimum acceptable for children age seven (7) and up.
Grades 7-10
One (1) dose of Tdap vaccine must be administered prior to entry.
K-3
Three (3) or more doses of IPV; the FINAL dose must be administered on or after the 4th birthday
regardless of the number of previous doses. If a combination of OPV and IPV was received, 4 doses of
either vaccine are required.
Grades 4-12
Three (3) or more doses of IPV or OPV. If the third dose of either series was received prior to the fourth
birthday, a fourth dose is required. If a combination of OPV and IPV was received, four (4) doses of either
vaccine are required.
K-12
Two (2) doses of MMR. Dose 1 must be administered on or after the first birthday. The second dose must
be administered at least 28 days after dose 1.
Hib
Haemophilus Influenzae
Type b
HEP B
Hepatitis B
Varicella
(Chickenpox)
None
K-12
Three (3) doses of Hepatitis B. The second dose must be administered at least 28 days after the first dose.
The third dose must be given at least 16 weeks after the first dose and at least 8 weeks after the second
dose. The last dose in the series (third or fourth dose) must not be administered before age 24 weeks.
K-3
Two (2) doses of varicella vaccine must be administered prior to entry. Dose 1 must be administered on or
after the first birthday. The second dose should be administered at least three (3) months after dose 1;
however, if the second dose is administered at least 28 days after first dose, it is considered valid.
Grade 4-7
One (1) dose of varicella vaccine must be administered on or after the first birthday
Students who have spent more than 90 consecutive days in a foreign country within the past 5 years must present proof of a
negative Tuberculin test performed in the United States.
CURRENTLY, WE DO NOT HAVE A RECORD OF THE FOLLOWING CIRCLED IMMUNIZATIONS.
Please provide the school clinic with proof of dates of these immunizations by: ____________________________
TYPE
DTP
Tdap
POLIO
MMR (combined)
HIB-d
HEPATITIS-B
MONTH / DAY / YEAR
TD (BOOSTER)
VARICELLA
OTHER
Physician/Health Department Signature/Stamp: __________________________________________________________
Students
5320 F1
Page 2 of 2
Revised 4/9/13
English
FRANKLIN COUNTY HEALTH DEPARTMENT IMMUNIZATION CLINIC INFORMATION
Appointments Required: call 614-525-3719 to schedule
Cost: $15.00 each shot
A parent/legal guardian must accompany their child. Bring your child’s past immunization records, a photo ID,
insurance card, and this form with you. No immunizations will be given without these records. All clinics are closed
on all legal holidays. NO TB skin tests are be given at any of these clinics. Non-English speaking families must bring
an interpreter.
FRANKLIN COUNTY CLINICS (for children 1 month to 18 years of age)
DUBLIN Community Rec. Center - 1st Weds each month
Address: 5600 Post Rd., Dublin
9:30 a.m. – 2:30 p.m.
HILLIARD Norwich Township Fire Station 83 - 2nd Wednesday of each month
Address: 4283 Davidson Road
9:30 a.m. – 2:30 p.m.
WESTERVILLE Division of Fire - 4th Monday of each month
Address: 400 West Main Street
9:30 a.m. – 2:30 p.m.
COLUMBUS PUCLIC HEALTH DEPARTMENT CLINIC INFORMATION
No appointments required. 1st come 1st served basis
Phone # for the Columbus Public Health Department: 645-7417
240 Parsons Avenue Columbus, OH 43215
Cost: $10.00 each shot
COLUMBUS PUBLIC HEALTH DEPARTMENT CLINICS (for children 1 month to 18 years of age)
Call 614-645-7417 for clinic hours.
WORTHINGTON United Methodist Church - 3rd Tuesday of every month 1 p.m. – 4 p.m.
600 High Street, Worthington, OH 43085 (maximum of 15 people per clinic)
Information for the Health Department Immunization Clinics can be accessed by visiting the following web
sites:
Franklin County Health Department Immunization Clinics
http://myfcph.org/imm.php
Columbus City Health Department Immunization Clinics
http://publichealth,columbus.gov/immunizations.aspx