Free Legal Notice Required Immunization for Admission to Wisconsin Schools, F-44001 - Wisconsin

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

STATE OF WISCONSIN s. 252.04, Wis. Stats

LEGAL NOTICE Required Immunizations (shots) for Admission to Wisconsin Schools To the Parent, Guardian or Legal Custodian of ____________________________Grade _____ The Student Immunization Law requires that all students through grade 12 meet a minimum number of required immunizations prior to school entrance. These requirements can be waived only for health, religious or personal conviction reasons. According to our records, your child is not compliant because either an immunization record is not available at school or an immunization(s) is needed (see reason for noncompliance marked below). To remain compliant with the law, please provide the month, day and year that your child received the required immunization(s) on the attached Student Immunization Record or select one of the waiver options prior to _________ and return the form to your child's school. Failure to do so may result in a fine of up to $25 per day or possible exclusion from school. If you have any questions about this notice, please contact your child's school. In past years, thousands of Wisconsin children caught diseases such as measles, pertussis (whooping cough) and rubella, and many were left with severe disabilities. The Student Immunization Law was passed in order to keep these and other vaccine-preventable diseases from returning and harming the health of our children. Reason for noncompliance: No Record Your child needs the following checked vaccines: 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

If your child already had chickenpox disease, varicella vaccine is not required. Check "yes" to the chickenpox disease question on the attached Student Immunization Record and enter the date of disease if known.

Your immediate cooperation is appreciated. ___________________________________________________________________________ School Phone ____________________________________________________________________________ School Official (Title) Date sent enc: Student Immunization Record