Immunizations Forms | Notifications

On 6/13/19, an amendment to public health law section 2164 passed which eliminates the exemption from vaccinations due to religious beliefs for school attendance. A Memo with information, guidance, and FAQs were sent to all schools. You can view the memo and FAQs on our Guidelines and Memos by Content page| Immunization here.


Documentation/Tracking Forms for Immunizations 

Immunization Survey Worksheets are located on the Data Reporting Page

OSAS Pertussis Booster Worksheet for Recording Immunizations  Worksheet to track students who are not yet 11 years old 12/16

2019-20 Immunization Requirements

2019-20 Immunization Requirements for School Attendance Chart NYSDOH (3/2019)

Letters to Parents/Guardians for 2019-2020 immunizations for students by grade

Sample Medical Exemption Letters/Forms

NYSDOH Dear Colleague letter regarding guidelines for use of immunization-related medical exemptions for school-aged children Provides guidelines for use by health care practitioners- to assist them in determining the appropriate use of immunization-related medical exemptions for school-aged children as well as providing a sample form for their use, and to assist school personnel with assessing accurate completion of medical exemption paperwork. (NYSDOH, 2016)

NYSDOH Immunization Requirements for School Attendance Medical Exemption Statement for Children 0-18 Years of Age Sample External link to the NYSDOH form for NYS physicians requestion medical exemption from immunization for their patients. This form must be completed annually. (NYSDOH, 5077 6/16)

Sample Medical Exemption Approval Letter with Notification of Exclusion During Communicable Disease Outbreak
This sample letter may be customized to inform parents/guardians that their child has that in the case of an outbreak, their child would be excluded for the length of contagion. Ideally, this information should be communicated when the exemption is granted. (NYSCSH, 6/2019)

Sample Exclusion Letters

Exclusion Letter for Principal to Send to Parents
Provides a sample which principals can customize to send letters to parents whose children have not received the required immunizations for school attendance (NYSCSH, 12/2016). 

Updated 6/26/19