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    Tdap Waiver 2011 CDPH 8261 Color

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    rhawk301
    This document is a personal beliefs exemption form from the California Department of Public Health regarding the pertussis (whooping cough) booster immunization requirement for school entry. The form requires a parent or guardian's signature to exempt their child from the immunization requirement due to personal beliefs. It explains that unimmunized children are at greater risk of contracting whooping cough, which can be life-threatening for infants and cause prolonged illness at any age. It also notes that exempted children may be excluded from school during outbreaks or exposure to protect other students.

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    Download as PDF, TXT or read online from Scribd

    Tdap Waiver 2011 CDPH 8261 Color

    Uploaded by

    rhawk301
    9K views1 page
    This document is a personal beliefs exemption form from the California Department of Public Health regarding the pertussis (whooping cough) booster immunization requirement for school entry. The form requires a parent or guardian's signature to exempt their child from the immunization requirement due to personal beliefs. It explains that unimmunized children are at greater risk of contracting whooping cough, which can be life-threatening for infants and cause prolonged illness at any age. It also notes that exempted children may be excluded from school during outbreaks or exposure to protect other students.

    Original Description:

    CDPH 8261 tdap 2011-2012 tdap waiver form I suggest crossing out "the unimmunized child" sentance.

    Original Title

    Tdap Waiver 2011 Cdph 8261 Color

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    This document is a personal beliefs exemption form from the California Department of Public Health regarding the pertussis (whooping cough) booster immunization requirement for school entry. The form requires a parent or guardian's signature to exempt their child from the immunization requirement due to personal beliefs. It explains that unimmunized children are at greater risk of contracting whooping cough, which can be life-threatening for infants and cause prolonged illness at any age. It also notes that exempted children may be excluded from school during outbreaks or exposure to protect other students.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    9K views1 page

    Tdap Waiver 2011 CDPH 8261 Color

    Uploaded by

    rhawk301
    This document is a personal beliefs exemption form from the California Department of Public Health regarding the pertussis (whooping cough) booster immunization requirement for school entry. The form requires a parent or guardian's signature to exempt their child from the immunization requirement due to personal beliefs. It explains that unimmunized children are at greater risk of contracting whooping cough, which can be life-threatening for infants and cause prolonged illness at any age. It also notes that exempted children may be excluded from school during outbreaks or exposure to protect other students.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    State of CaliforniaHealth and Human Services Agency

    California Department of Public Health

    Personal Beliefs Exemption


    Pertussis (Whooping Cough) Booster Immunization [Tdap] Requirement

    OCDPH

    STUDENT NAME (Last, First, Middle)

    BIRTH DATE

    MM NAME OF PARENT/GUARDIAN PHONE NUMBER

    DD

    YYYY

    HOME ADDRESS: STREET

    ZIP CODE

    PERSONAL BELIEFS AFFIDAVIT TO BE SIGNED BY PARENT OR GUARDIANIMMUNIZATION.


    The unimmunized child and the child's contacts at school and home are a greater risk of becoming sick with pertussis, which can be life-threatening for young infants and can cause prolonged illness at any age. I understand that, for the protection of the child and other students, the child may be excluded from attending school for prolonged periods during each outbreak of pertussis or after each exposure to someone with pertussis. (17 OCR 6060) I hereby request exemption of the child named above from the pertussis (whooping cough) immunization requirement for school entry because such immunization is contrary to my beliefs.

    Signature of parent or guardian:

    Date:

    CREENCIAS PERSONALES: ESTA DECLARACION JURADA DEBE SER FIRMADA POR EL PADRE 0 LA MADRE 0 EL GUARDIAN
    Un nirio no vacunado y asi como sus contactos en la escuela y el hogar tienen mayor riesgo de enfermarse de la tos ferina, lo cual puede poner en peligro la vida de los bebes, y puede causar una enfermedad prolongada a cualquier edad. Entiendo que, para la proteccion del nitio y otros estudiantes, el nifio puede quedar excluido de asistir a la escuela durante periodos prolongados durante cada brote de tos ferina, o despu6s de quedar expuesto a alguien con tos ferina. (17 OCR 6060) Por la presente solicito que el nifio mencionado arriba quede exento del requisito de la vacuna contra la tos ferina para entrar a la escuela, porque dicha vacuna va en contra de mis creencias.

    Firma del padre o la madre o el guardian:

    Fecha:

    The California Department of Public Health (CDPH) recognizes that your privacy is a personal and fundamental right. The CDPH values and protects your privacy and places strict controls on the gathering and use of personally identifiable data. Your personal information is not disclosed, made available, or otherwise used for purposes other than those specified at the time of collection, except with your consent or as authorized by law or regulation. The Department's information management practices are consistent with the Information Practices Act (Civil Code Section 1798 et seq.), the Public Records Act (Government Code Section 6250 et seq.), Government Code Sections 11015.5 and 11019.9, and with other applicable laws pertaining to information privacy.

    CDPH 8261 (01/11)

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