Exclusion Notice for Inadequate Immunizations
(DATE)
Dear Parent/Guardian:
A recent review of immunization records shows that your child, (NAME) may not be adequately
immunized as required by the Utah Immunization Rule for Students (R396-100). Please obtain
complete dates for the indicated immunizations and provide a record to us by (DATE) or your
child will be excluded from attending school on (DATE) under Utah Statutory Code (53A-11-306).
THE BOXES MARKED BELOW INDICATE DOSES NEEDED FOR YOUR CHILD’S RECORDS.
Vaccine
DTaP/DT/Td*
1
2
3
Tdap Booster*
4
1
2
MMR (Measles, Mumps,
Rubella)
3
1
A. Dates or doses
are missing or
incomplete.
B. Previous dose(s)
was/were given
too close together.
C. Previous dose(s)
was/were given at
too young an age.
4
2
*D = Diphtheria
Hepatitis B
1
2
*T = Tetanus
3
*P = Pertussis
Haemophilus Influenzae
Type b (Hib)
1
2
3
Varicella (chickenpox)
1
2
Hepatitis A
1
2
Meningococcal
5
1
Polio
Pneumococcal (PCV13)
Reason
(see codes
to right)
Dose in Question
(circle dose number)
1
2
3
4
4
5
1
If we do not receive this information from you before the date indicated, we will be forced to
exclude your child from attendance. We regret that we must take this action, but state law
requires that children must be appropriately immunized in order to attend a Utah school or early
childhood program. Our facility supports this policy. If you have questions or need additional
information, please call (TELEPHONE NUMBER).
Sincerely,