SAMPLE LETTER A

[TO BE PLACED ON SCHOOL DISTRICT STATIONERY]

[date]

[Parent(s)]
[Address]

Re:	Immunizations

Dear Parent:

As you know, school begins on [date].  Before your child, [name of child], can be enrolled, however, we must receive proof that he/she has received immunization against a number of diseases as required by state law or is excepted therefrom.  To date, we have no immunization records for your child nor a claim of exception.

Please complete the enclosed form verifying that [name of child] has received the required immunizations, consistent with medically acceptable standards and return the form to [name of school official], before school begins.  By state law, we cannot allow [name of child] to stay in school longer than thirty days unless we have received proof that he/she has had the required immunizations or is excepted therefrom.

If you cannot submit a statement from a physician or public clinic regarding your elementary or secondary school child, you may submit your own statement on the enclosed form detailing the precise dosages given for each required immunization and the month and year each immunization was given.  If you elect to submit your own statement in lieu of one from a health care provider, please contact the District Health Coordinator at 218-749-8130 to determine the precise vaccinations required for your child, as the requirements vary according to the child’s age.

If you are claiming an exception for medical reasons that an immunization is contraindicated or because of your conscientiously held beliefs, you must either submit a statement from a physician stating the immunization is contraindicated or you must submit a notarized statement, signed by you as the parent/guardian, or if the student is an emancipated person, by the emancipated person, stating that the student has not been immunized because of conscientiously held beliefs.  The enclosed form may be used for this purpose.

If we do not receive proof of immunization or exception by [date], your child will be sent home from school and discharged from enrollment.  It will then be necessary for you to re-enroll the child after immunization requirements have been met before the child can return to school.  If you have any questions, please contact the District Health Coordinator at 218-749-8130.

Thank you for your cooperation.

Sincerely,

(Printed Name)
District Health Coordinator

SAMPLE LETTER B

[TO BE PLACED ON SCHOOL DISTRICT STATIONERY]
[date]

[Parent(s)]
[Address]

Re:	Immunizations

Dear Parent:

As you know, school began today.  To date, we have no immunization records for your child nor any record of a request for an exception.  In order for your child, [name of child], to remain enrolled, we must receive proof that he/she has received immunization against a number of diseases as required by state law or that he/she qualifies for one of the statutory exceptions.  By this letter, we wish to verify that our records concerning your child are accurate and complete.

Please submit a statement on the enclosed form to the District Health Coordinator from a physician or a public clinic verifying that [name of child] has received the required immunizations, consistent with medically acceptable standards.  By state law, we cannot allow [name of child] to stay in school unless we have received proof that he/she has had the required immunizations or has satisfied one of the statutorily recognized exceptions.

If you cannot submit a statement from a physician or public clinic regarding your elementary or secondary school child, you may submit your own statement on the enclosed form detailing the precise dosages given for each required immunization and the month and year each immunization was given.  If you elect to submit your own statement in lieu of one from a health care provider, please contact the District Health Coordinator at 218-749-8130 to determine the precise vaccinations required for your child, as the requirements vary according to the child’s age.

If you are claiming an exception for medical reasons that an immunization is contraindicated or because of your conscientiously held beliefs, you must either submit a statement from a physician stating the immunization is contraindicated or you must submit a notarized statement, signed by you as the parent/guardian, or if the student is an emancipated person by the emancipated person, stating that the student has not been immunized because of conscientiously held beliefs.  The enclosed form may be used for this purpose.

If you have already submitted a statement to us, please indicate how the statement was submitted (i.e. hand-delivered, mailed), when it was delivered and to whom.  It may be necessary for you to obtain a duplicate statement if the original cannot be found.  If additional time to obtain a duplicate is required, please so indicate in your response.

If we do not receive proof of immunization or exception by [ten school days], your child will be sent home from school and discharged from enrollment.  It will then be necessary for you to re-enroll the child after immunization requirements have been met before the child can return to school.  If you have any questions, please contact the District Health Coordinator at 218-749-8130.

Thank you for your cooperation.

(Printed Name)
District Health Coordinator

SAMPLE LETTER C

[TO BE PLACED ON SCHOOL DISTRICT STATIONERY]

[date]

[Parent(s)]
[Address]

Re:	Non-Enrollment for Lack of Immunization Proof

Dear Parent:

We are sending your child, [name of child], home today because we have not yet received proof that he or she has received appropriate immunizations or is excepted therefrom.  Minnesota law does not allow us to enroll an elementary or secondary school student without proof that the student has received the required immunizations or is excepted therefrom.

As we advised earlier, State law and School District policy allow for a thirty-day grace period and a ten-day due process period during which your child may attend school.  Those grace periods have now expired.

[Name of child] may re-enroll as soon as we have received appropriate proof of immunizations.  If you have any questions about the proof or the immunizations required, please contact the District Health Coordinator at 218-749-8130 as soon as possible.

We look forward to having [name of child] back in school soon.

Sincerely,

(Printed Name)
District Health Coordinator

DISTRICT NOTES:

Previous notices sent on	__________ by ________________________________

Phone contacts on		__________ by ________________________________

				__________ by ________________________________

				__________ by ________________________________

ATTACHMENT D

Student Immunization Form

FOR SCHOOL USE ONLY
(   ) Complete; booster required in _______________
(   ) In process; 8 mos. expires __________________
(   ) Medical exemption for _____________________
(   ) Conscientious objection for _________________
(   ) Parental/guardian consent __________________

Student Name______________________________________________

Birthdate___________________ Student Number__________________

Minnesota law requires children enrolled in school to be immunized against
certain diseases or file a legal medical or conscientious exemption.

Parent/Guardian:
You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received.  Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs.
Sign or obtain appropriate signatures on reverse.  Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption.
Additionally, if a parent or guardian would like to give permission to the school to share their child’s immunization record with Minnesota’s immunization information system, they may sign section 3 (optional).
For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.

School Personnel:  Be sure to initial and date any new information that you add to this form after the parent/guardian submits it.  Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space.
Type of Vaccine               DO NOT USE (✓) or (✗)	1st Dose
Mo/Day/Yr	2nd Dose
Mo/Day/Yr	3rd Dose
Mo/Day/Yr	4th Dose
Mo/Day/Yr	5th Dose
Mo/Day/Yr	
Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.)	
Diphtheria, Tetanus, and Pertussis (DTaP,DTP DT)
• for children age 6 years and younger
• final dose on or after age 4 years						
				5th dose not required if 4th dose was given on or after the 4th birthday	
Tetanus and Diphtheria (Td)
• for children age 7 years and older
• 3 doses of Td required for children not up to date with
  DTaP, DTP, or DT series above			

Tetanus, Diphtheria, and Pertussis (Tdap)
• for children in 7th - 12th grade						
Polio (IPV, OPV)
• final dose on or after age 4 years							
			4th dose not required if 3rd dose was given on or after the 4th birthday		
Measles, Mumps, and Rubella (MMR)
• minimum age: on or after 1st birthday						
Hepatitis B (hep B)
						
 Varicella (chickenpox)
• minimum age: on or after 1st birthday
• vaccine or disease history required						
Meningococcal (MCV, MPSV)
• for children in 7th - 12th grade
• booster given at age 16 years			
			
Recommended	
Human Papillomavirus (HPV)						
Hepatitis A (hep A)						
Influenza (annually for children 6 months and older)						
Additional exemptions:
•	Children 7 years of age and older:  A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the minimum requirements of the law.
•	Students in grades 7-12:  A Tdap at age 11 years or later is required for students in grades 7-12.  If a child received Tdap at age 7-10 years, another dose is not needed at age 11-12 years.  However, if it was only a Td, a Tdap dose at age 11-12 years is required. 
•	Students 11-15 years of age:  A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the alternative 2-dose schedule.
•	Students 18 years of age or older:  Do not need polio vaccine.

Developed by the Minnesota Department of Health - Immunization Program                www.health.state.mn.us/immunize                  (12/13) #140-0155

Student Name__________________________________________

Instructions, please complete:
Box 1 to certify the child’s immunization status
Box 2 to file an exemption (medical or conscientious)
Box 3 to provide consent to share immunization information (optional)
1.	Certify Immunization Status. Complete A or B to indicate child’s immunization status.	
A.	Received all required immunizations:

I certify that this student has received all immunizations required by law.

___________________________________________
Signature of Parent / Guardian OR Physician / Public Clinic

________________ Date

	B.	Will complete required immunizations within the next 8 months:

I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B, varicella, measles, mumps, and rubella and will complete his/her diphtheria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months.

The dates on which the remaining doses are to be given are:

____________________________________________
Signature of Physician / Public Clinic

________________ Date	

2.	Exemptions to School Immunization Law. Complete A and/or B to indicate type of exemption.	
A.	Medical exemption:
No student is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity.  For a student to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement:

I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below).  List exempted immunization(s):

____________________________________________
Signature of physician/nurse practitioner/physician assistant

________________ Date

     *	History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in _______ (year)

____________________________________________
Signature of physician/nurse practitioner/physician assistant  (If disease occurred before September 2010, a parent can sign.)	B.	Conscientious exemption:
No student is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian.  However, not following vaccine recommendations may endanger the health or life of the student or others they come in contact with.  In a disease outbreak schools may exclude children who are not vaccinated in order to protect them and others.  To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized:

I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s):

____________________________________________
Signature of parent or legal guardian

________________ Date

Subscribed and sworn to before me this:
________ day of _____________________ 20______

____________________________________________
Signature of notary	

3.	Parental/Guardian Consent to Share Immunization Information (optional):
Your child’s school is asking your permission to share your child’s immunization documentation with MIIC, Minnesota’s immunization information system, to help us better protect students from disease and allow easier access for you to retrieve your child’s immunization record.  You are not required to sign this consent; it is voluntary.  In addition, all the information you provide is legally classified as private data and can only be released to those legally authorized to receive it under Minnesota law.

I agree to allow school personnel to share my student’s immunization documentation with Minnesota’s immunization information system:

________________________________________________________________________________________________
Signature of parent or legal guardian                                                                                                    Date	

Developed by the Minnesota Department of Health - Immunization Program                www.health.state.mn.us/immunize                  (12/13) #140-0155