SCHOOL HEALTH SERVICES
Fair Lawn, New Jersey
To:
In order for a pupil to meet the requirements for public school entrance, all
immunizations must be current. Immunizations must be given by _____________
or the pupil will be excluded until documentation from the physician has been
submitted to the school.
Name_________________________ DOB_____________ School_______________
_____DPT – Diptheria, Whooping Cough, Tetanus – for children less than 7 y/o - 4 doses, with the LAST
DOSE AFTER 4TH BIRTHDAY. Alternatively, any child with a total of 5 doses is in compliance.
1.____________
2.____________
3.____________
4.____________
5.____________
_____Tdap – age 7 or older, 3 doses of Td (adult) or a combination of DTP, DTAP, DTP/Hib or DTAP/Hib,
DT and Td totaling 3 doses.
1.____________
2.____________
3.____________
_____Tdap – (born after 1-1-1997) – 1 dose ____________
_____POLIO – For those children less than 7 y/o, a minimum of 3 doses of OPV or enhanced IPV is
required provided at least one dose is given on or after the 4th birthday. For children older than 7y/o, 3
doses will satisfy the requirement. Alternatively, any 4 doses spaced by a minimum of one month (28 days)
are also in compliance.
1.____________
2.____________
3.____________
4.____________
_____MEASLES (RUBEOLA) – 2 doses of Measles containing vaccine given after the 1st birthday,
(preferably MMR) is required. The 2 doses must be given at least one month apart. Documented
laboratory evidence of immunity is acceptable in lieu of second dose.
1.____________
2.____________
_____GERMAN MEASLES (RUBELLA) – one dose of Rubella virus or a combination containing
Rubella live virus vaccine must be given on or after 1st birthday. This immunization is not required for pupils
who present laboratory evidence of Rubella immunity.
____________
_____MUMPS – Every pupil shall have received one dose of Mumps virus vaccine on or after the 1st
birthday. Documented laboratory evidence of Mumps immunity is acceptable.
____________
_____HEPATITIS B – 3 doses of Hepatitis B vaccine is required. Second dose given 1-3 months after
the first. Third dose given 6-12 months after initial dose to be in compliance.
1.____________
2.____________
3.____________
_____VARICELLA – First dose after first birthday, second dose recommended. Or documentation of
disease.
1.____________
2.____________
_____MENINGOCOCCAL – (born on or after 1-1-1997) – 1 dose ____________
**Please return this form to the school nurse Mrs. Frotten, RN **
Date: _____________
Gary Muccino, M.D
Medical Inspector
H-27(revised0911)
Physician’s Signature: _____________________________________
_____________________________________
________________________________
________________________________
Physician’s Printed Name & Address