IMMUNIZATIONS (Highlighted in Blue) ARE REQUIRED for all Students
Immunizations must be approved by the school Health Aide before being accepted to the school and before an I-20 can be sent to Foreign Student.
Hepatitis B (HepB): Required for all students.	At least 3 doses of the Hepatitis B vaccine (with 4 weeks between dose 1 and dose 2 and 8 weeks between dose 2 and 3; (3rd dose should be at least 16 weeks after 1st dose). A 2-dose series of Recombivax HB® is licensed for students aged 11-15 years.
DPT (Diphtheria / Pertussis / Tetanus): Required for all students.	At least 4 doses with the last dose given after the age of 4.
Tdap (Tetanus and diphtheria toxoids and acellular pertussis vacine) OR Td (Tetanus and diphtheria toxoids)	Tdap should be substituted for a single dose of Td in the primary catch-up series or as a booster if age appropriate; use Td for other doses. A 5-year interval from the last Td dose is encouraged when Tdap is used as a booster dose. Thereafter a booster Td is required every 5 years.
HIB (Haemophilus influenzae type b conjugate vaccine):	Not recommended aged > 5 years old.
Polio:(IPV or OPV): Required for all students.	At least 3 doses, with the last dose being given after the age of 4.
MMR: (Measles, Mumps, Rubella) (Required for all students)	At least 2 doses with the 1st dose on or after one year of age with > 4 weeks between the two doses. (Must show proof signed by doctor if immunity to Measles). If single doses for Measles or Mumps or Rubella were given separately, please record them separately. Must have 2 doses of each.
Varicella (Chicken Pox): 2 doses required for all students.	1. Must show evidence of immunity by titer if student has had the disease.
	2. If no proof of immunity, then administer 2 doses of varicella vaccine to persons aged > 13 years old with doses at least 4 weeks apart.
PCV (Pneumococcal): (Not generally recommended for students aged > 5 years except for high risk groups)	Administered for certain high-risk groups such as: diabetes, chronic lung (except asthma), heart, kidney or liver disease, or alcholism; those whose immune systems have been weakened by such conditions as cancer or HIV infection; people without a functional spleen and those with sickle cell disease.
Meningcoccal (MCV4): (Required for all students)	Required for all foreign students. Administer MCV4  to previously unvaccinated adolescents at high school entry (at approximately age 15 years).
Influenza: (Recommended)	Yearly (For healthy persons aged 5-49 years, LAIV may be sued as an alternative to TIV.
Hep A (Hepatitis A): (Recommended) Required for all foreign students.	At least 2 doses of the Hepatitis A vaccine (with 6 months between the 2 doses)
Tuberculin Test:	Date:
			(       ) positive		Date:	(      ) negative
Please explain any positive reaction and follow-up:
Has the student received a BCG immunization?___________________________ If yes, when?________________
Proof of immunity to any disease includes a signed statement from a physician indicating that the student has had a confirmed case of disease or confirmation by specific blood test conducted by a certified laboratory.