Woodbury City Public Schools
School Health Office
Immunization Deficiencies
(Deficiencias de la inmunizacion)
To the Parent/ Guardian of
DOB / /
Your child’s health record shows the following immunizations are incomplete. The boxes checked below
indicate the dates that are missing.
Vaccine Type
DPT, Td
Polio
MMR
Measles
Rubella
Mumps
HIB
Hepatitis B
Mantoux
Varicella
Pneumococcal Vaccine (PreK)
Influenza (PreK)
Meningococcal Vaccine (Gr. 6)
Tdap (Gr.6)
Primary Series Doses
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First
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Booster
4 Year
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Immunization Requirements (effective June 2012)
DPT: Age 1-6 years: 4 doses, with one dose given on or after the 4th birthday, OR any 5 doses.
Tdap: Grade 6: 1 dose
Polio: Age 1-6 years: 3 doses, with one dose given on or after the 4th birthday, OR any 4 doses
Measles: 2 doses of a live measles containing vaccine on or after the 1st birthday.
Rubella and Mumps: 1 dose of live rubella- mumps-containing vaccine on or after the 1st birthday.
Varicella: 1 dose on or after 1st birthday
HIB: 1 dose after 1st birthday- (Preschool only)
Hepatitis B: 3 doses
Pneumococcal vaccine: Age 12-59 months- 1 dose (Preschool only)
Meningococcal Vaccine: Grade 6
Influenza Vaccine: Age 12-59 months- 1 dose annually (Preschool only)
Your doctor or clinic must administer the required immunization, and the confirmation of the administration must be
given to the Nurse on or before ___________________________. Must show at least 1 dose of DPT, Polio &
MMR for admission to school. After that date, the student will be excluded from school until the immunization is
administered.
Physician’s Name (print): ____________________________________________________________
Physician’s Signature: ______________________________________________________________
Physician’s Address: ___________________________________________________________________
Physician’s Phone Number: ________________________ Date of Examination_________________
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