Free Student Immunization Record, F-04020LH - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health DAIM F-04020LH (Rev. 02/08)

NTAWV TEEV ME NYUAM KAWM NTAWV KEV TXHAJ TSHUAJ

STUDENT IMMUNIZATION RECORD

STATE OF WISCONSIN 252.04 and 120.12 (16) Wis. Stats.

LUS QHIA RAU NIAM TXIV: UA KOM TIAV THIAB XA MUS RAU TSEV KAWM NTAWV TSIS PUB DHAU 30 HNUB TOM QAB TAU KAWM NTAWV LAWM. Lub xeev txoj cai yuav tsum kom txhua tus me nyuam kawm ntawv nyob rau hauv tsev kawm ntawv luam thiab tsev kawm ntawv ntiav muaj ntaub ntawv pov thawj txog kev txhaj tshuaj tiv thaiv tej txhia kab mob tsis pub dhau 30 hnub tom qab tau kawm ntawv lawm. Cov ntaub ntawv qhia txog lub hnub nyoog tam sim no/kawm nyob qib twg uas yuav tsum tau txhaj koob txhuaj twg muaj nyob rau hauv tsev kawm ntawv thiab cov chaw ua hauj lwm saib xyuas kev noj qab haus huv. Yuav kom zam tau tsis txhob raug txhaj tshuaj mas yuav tau kos npe rau daim ntawv tsis pub txhaj tshuaj vim muaj mob, muaj kev ntseeg ntuj/dab qhuas los yog kev ntseeg tus kheej tso rau hauv tsev kawm ntawv. Lub hom phiaj ntawm daim ntawv no tsuas yog ntsuas txog qhov ua kom raws li txoj cai thiab tsuas muab siv rau qhov hauj lwm no nkaus xwb. Yog koj muaj lus nug txog kev txhaj tshuaj los yog yuav ua daim ntawv no kom tiav li cas, nug mus rau koj tus me nyuam lub tsev kawm ntawv los yog qhov chaw ua hauj lwm saib xyuas kev noj qab haus huv ntawm koj. QHIA TXOG TUS KEEJ (PERSONAL DATA) THOV SAU COV NTAWV KOM POM ZOO (PLEASE PRINT) Tus Me Nyuam Kawm Ntawv Lub Npe Hnub Yug Hli/Hnub/Xyoo) Poj Niam/Txiv Neej Tsev Kawm Ntawv Qib Xyoo Kawm Ntawv Kauj Ruam Step 1 Niam Txiv/Tus Saib Xyuas Lub Npe Chaw Nyob (Txoj Kev, Lub Zos, Xeev, Zip Code Xov Tooj ( Kauj Ruam Step 2 ) KEEB KWM TXHAJ TSHUAJ (IMMUNIZATION HISTORY) Teev lub HLI, HNUB, THIAB XYOO koj tus me nyuam tau txhaj cov tshuaj raws li nram qab no. TSIS TXHOB SIV IB TUG () LOS YOG (X) tshwj yog teb rau los lus nug txog mob chickenpox xwb. Yog koj tsis muaj daim keeb kwm ntawv txhaj tshuaj rau tus me nyuam kawm ntawv no nyob tom tsev, nug mus rau koj tus kws kho mob los yog qhov chaw ua hauj lwm saib xyuas kev noj qab haus huv kom tau ib daim. KOOB THIB PLAUB THAWJ KOOB KOOB THIB OB KOOB THIB PEB KOOB THIB TSIB HOM TSHUAJ*
Hli/Hnub/Xyoo Hli/Hnub/Xyoo Hli/Hnub/Xyoo
Hli/HnubyXyoo

Hli/Hnub/Xyoo

DTaP/DTP/DT/Td/Tdap (Diphtheria, Tetanus, Pertussis)
Txhaj ntxiv thaum nto hluas lawm (Kos rau qhov yog) Tdap Td

Polio Hepatitis B MMR (Measles, Mumps, Rubella) Cov tshuaj Varicella (Chickenpox) tsuas yog siv tau rau koj tus me nyuam uas tsis tau raug tus mob chickenpox xwb. Xyuas hauv qab no. Koj tus me nyuam puas tau muaj tus mob Varicelle (chickenpox) dua? Kos rau kab kom yog thiab qhia lub xyoo yog hais tias koj paub: Tau Mob Dua Lawm (yes) ___________________xyoo (Tsis tas txhaj tshuaj lawm) Tsis Tau Mob Dua (No) los yog Tsis Paub Tseeb (Yuav tau txhaj tshuaj) YAM YUAV TSUM TAU UA (REQUIREMENTS) Kauj Ruam Step 3 Kauj Ruam Step 4 Mus xyuas ntawm daim ntawv teev qhia txog lub hnub nyoog/kawm nyob qib twg rau lub xyoo kawm ntawv no kom paub seb tus me nyuam kawm ntawv no puas tau txhaj cov tshuaj kom puv raws li qhov yuav tsum tau txhaj. MUAJ TXHIJ TAS RAWS LI TXOJ CAI (COMPLIANCE DATA) TUS ME NYUAM KAWM NTAWV MUAJ TXHIJ RAWS LI TXOJ CAI Kos lub npe rau Kauj Ruam 5 thiab xa daim ntawv mus rau tsev kawm ntawv. Los Yog TUS ME NYUAM KAWM NTAWV TSIS TAU MUAJ TXHIJ RAWS LI TXOJ CAI Xyuas cov nqe lus hauv qab no seb qhov twg haum, kos npe rau Kab Thib 5, thiab xa daim ntawv rov tuaj rau tsev kawm ntawv. THOV KOM NCO HAIS TIAS COV ME NYUAM KAWM NTAWV UAS TXHAJ TSHUAJ TSIS PUV YUAV RAUG TSHEM TAWM NTAWM TSEV KAWM NTAWV MUS YOG HAIS TIAS MUAJ IB TUS KAB MOB NTAWM COV MOB NO TSHWM SIM KIS THOOB PLAWS QHOV TXHIA CHAW. Txawm hais tias kuv tus me nyuam TSIS TAU txhaj TAG NRHO cov tshuaj uas yuav tsum tau txhaj, THAWJ KOOB twb txhaj tag lawm. Kuv to taub hais tias koob THIB OB yuav tsum tau txhaj tsis pub dhau 90 hnub tom qab tau kawm ntawv rau xyoo no, thiab KOOB THIB PEB thiab THIB PLAUB yog hais tias yuav tsum tau txhaj mas yuav tsis pub dhau 30 hnub tom qab kawm ntawv xyoo tom ntej. Kuv kuj to taub hais tias nws yog kuv lub luag hauj lwm los sau ntawv ceeb toom rau tsev kawm ntawv txhua zaus kuv tus me nyuam tau txhaj koob tshuaj uas yuav tsum tau txhaj. CEEB TOOM: Yog tsis ua raws li tau teem tseg thiab tsis qhia rau tsev kawm ntawv tej zaum yuav raug plaub thiab raug nplua txog li ntawm $25.00 rau ib hnub uas tau ua txhaum. COV NQE LUS TSIS PUB TXHAJ TSHUAJ (WAIVERS) (Teev nyob Kauj Ruam 2 saud, cov hnub uas koj tus me nyuam tau txhaj tshuaj lawm). Vim kev muaj mob tus me nyuam kawm ntawv no yuav tsum tsis txhob txhaj cov tshuaj nram qab no ______________________________________________________________ KOS NPE - Kws Kho Mob _______________________________________ Hnub Kos Npe
*koob tshuaj Hib tsuas yog siv rau cov me nyuam uas nyob rau hauv cov chaw zov me nyuam muaj ntaub ntawv pov thawj xwb. Tsis txhob sau hnub uas koj tus me nyuam tau txhaj koob tshuaj Hib rau daim ntawv no.

Vimb kev ntseeg ntuj/dab qhuas tus me nyuam kawm ntawv no yuav tsum tsis txhob muab tshuaj txhaj nws. Vim kev ntseeg tus keej tus me nyuam kawm ntawv no yuav tsum tsis txhob muab tshuaj txhaj nws. _______________________________________________________________________________________________________________ TEEV COV TSHUAJ UAS TSIS PUB TXHAJ KOS NPE Daim ntawv no ua tiav thiab muaj tseeb raws li qhov kuv paub. ___________________________________________________________________ __________________________________________ KOS NPE ­ Niam Txiv/Tus Muaj Cai Saib Xyuas los yog Tus Me Nyuam Kawm Ntawv Uas Nws Loj Lawm (Adult Student) Hnub Kos Npe

Kauj Ruam Step 5