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Get CA CDPH 286 2002

Local health departments shall have access to this record in schools, child care facilities, and family day care homes. This record must be completed by school and child care personnel from an immunization record provided by parent or guardian. See reverse side for instructions. Student Name Sex: Name of Parent or Guardian Race/Ethnicity: M F Birthdate Place of Birth Address White, not Hispanic Hispanic Telephone Daytime Nighttime City Black ZIP Other: DATE EACH DOSE WAS GIVEN.

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