Dublin City School District
Immunization Requirements – K-12
Students
5320 F1
Page 1 of 2
Revised 5/24/12
English
To the Parent of: ___________________________________________________
D.O.B. ______________________
From: ____________________________________________________________
Date: ________________________
FOR THE 2012-2013 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 2012
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
Three (3) 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 7-9
One (1) dose of Tdap vaccine must be administered prior to entry.**
K-2
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 3-12
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-2
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 3-6
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
MONTH / DAY / YEAR
DPT
TD (BOOSTER)
POLIO
MMR (combined)
HIB-d
HEPATITIS-B
VARICELLA
OTHER
Physician/Health Department Signature/Stamp: __________________________________________________________
Students
5320 F1
Page 2 of 2
Revised 5/24/12
English
IMMUNIZATION CLINIC INFORMATION
(Cost: $15.00 assessment fee + $10.00 EACH SHOT)
A parent/legal guardian must accompany their child. Bring your child’s past immunization records, your ID and this
form with you. No immunizations will be given without these records. No appointments are necessary/first come first
served. All clinics are closed on all legal holidays. Immunizations only are administered at all of the below clinics.
NO TB skin tests can be given at any public health department clinics.
FRANKLIN COUNTY CLINICS (for children 1 month to 18 years of age)
Phone # for all clinics: 462-3160
Non-English speaking families must bring an interpreter
Walk-in every Friday, 9 a.m. – 11:30 a.m.
DUBLIN Community Rec. Center
Address: 5600 Post Rd., Dublin
1st Weds each month
9:30 a.m. – 12:30 p.m. and 1 p.m. – 3 p.m.
HILLIARD Norwich Township Fire Station 83
Address: 4283 Davidson Road
2nd Wednesday of each month
9:30 a.m. – 12:30 p.m. and 1 p.m. – 3 p.m.
WESTERVILLE Division of Fire
Address: 400 West Main Street
2nd Thursday of each month and 4th Friday of each month
9:30 a.m. – 12:30 p.m. and 1 p.m. – 3 p.m.
COLUMBUS PUBLIC HEALTH DEPARTMENT CLINICS (for children 1 month to 18 years of age)
Phone # for the Columbus Public Health Department: 645-7417
240 Parsons Avenue Columbus, OH 43215
Monday
8 a.m. – 4:15 p.m.
Tuesday 11 a.m. – 6:15 p.m.
Wednesday
CLOSED
Thursday 8 a.m. – 4:15 p.m.
Friday
8 a.m. – 4:15 p.m.
2nd Saturday of every month 8 a.m. – 12 p.m.
WORTHINGTON United Methodist Church
600 High Street, Worthington, OH 43085 3rd Tuesday of every month 1 p.m. – 4 p.m.
Columbus Public Health Department Clinics also provide TD, Tdap, and Influenza vaccines to adults ONLY age 19 and
over.
Cost:
TD - $10.00 + $15.00 assessment fee
Tdap - $45.00 + $15.00 assessment fee
Influenza (seasonal shot) - $10.00 + $15.00 assessment fee