Free Legal Notice Required Immunization (shots) For Admission to Wisconsin Schools, F-44001H - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44001H (Rev. 07/08)

STATE OF WISCONSIN s. 252.04, Wis. Stats

DAIM NTAWV CEEB TOOM RAUG CAI (Legal Notice) Yuav Tsum Tau Txhaj Tshuaj Yog Kawm Ntawv nyob rau covTsec Kawm Ntawv nyob Wisconsin Txog rau cov Niam Txiv los yog cov Muaj Cai saib xyuas ntawm ______________Grade _____ Txoj Cai Me Nyaum Kawm Ntawv Txhaj Tshuaj (The Student Immunization Law) yuav kom txhua tus me nyuam kawm ntawv mus txog rau qib 12 yuav tsum tau txhaj tshuaj kom txaus ua ntej yuav pib kawm ntawv. Yuav kom zam tau tsis txhob raug txhaj cov tshuaj no mas yuav tau kos npe rau daim ntawv kom muaj kev zam tso rau ntawm tsev kawm ntawv qhia tau tias vim muaj mob, muaj kev ntseeg ntuj (dab qhuas) los yog ntseeg yus tus keej. Raws li peb cov ntawv keeb kwm uas teev tsheg, koj tus me nyuam daim ntawv txhaj tshuaj tsis muaj nyob rau ntawm peb tsev kawm ntawv los yog yuav tau txhaj tshuaj ntxiv (xyuas hauv qab no seb yog li cas thiaj li ua tsis raug cai). Yuav ua kom raug txoj cai, thov sau lub hli, hnub thiab xyoo uas koj tus me nyuam tau txhaj cov tshuaj yuav tsum tau txhaj rau daim ntawv Keeb Kwm Txhaj Tshuaj (Student Immunization Record) ua muaj nrog ua ke no los yog xaiv ib qho kev zam ua ntej ntawm __________ thiab xa daim ntawv no mus rau koj tus me nyuam lub tsev kawm ntawv. Yog ua tsis tau tej zaum yuav raug npua $25 rau ib hnub los yog ntshe yuav raug cais tawm ntawm tsev kawm ntawv. Yog hais tias koj muaj lus nug txog rau daim ntawv ceeb toom no, thov hu mus rau koj tus me nyuam lub tsev kawm ntawv. Ntau xyoo yav dhua los, muaj txhiab tawm tus me nyuam kawm ntawv nyob Wisconsin raug tus mob xus li measles, pertussis (whooping cough) thiab rubella, thiab muaj coob tus tau siam hoob qhab loj. Txoj Cai Me Nyuam Kawm Ntawv Txhaj Tshuaj tau tsa kom muaj los pab tiv thaiv cov kab mob kom tsis txhob rov muaj dua thiab kom tsis txhob raug rau cov peb cov me nyuam tej kev noj qab hau huv. Yog li cas thiaj tsis txhaj tshuaj kom txaus: Tsis Muaj Keeb Kwm Uas Teev Tseg Koj tus me nyuam yuav tau txhaj koob tshuaj kos nyob rau nram qab no: DTP/DTaP/DT/Td 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose Polio 1st Dose 2nd Dose 3rd Dose 4th Dose MMR 1st Dose 2nd Dose Hepatitis B 1st Dose 2nd Dose 3rd Dose Varicella* 1st Dose 2nd Dose Tdap 1st Dose

* Yog hais tias koj tus me nyuam twb muaj mob chickenpox lawm, tsis tas txhaj koob tshuaj varicella. Kos "yes" rau los lus nug txog tus mob chickenpox ntawm caim ntawv Keeb Kwm Txhaj Tshuaj thiab sau vas thib rau yog hais tias paub. Ua tsaug rua koj txoj kev koom tes. ___________________________________________________________________________ Tsev Kawm Ntawv Xov Tooj ___________________________________________________________________________ Tsev Kawm Ntawv Tus Neeg Ua Hauj Lwm (Title) Hnub xa tawm

enc: Daim Ntawv Keeb Kwm Txhaj Tshuaj (Student Immunization Record)