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Get NY OCFS-LDSS-4433 2019-2024

E of Child: Date of Birth: Date of Examination:          /    /         /    /      Immunizations required for entry into day care Medical Exemption The physical condition of the named child is such that one or more of the immunizations would endanger life or health. Attach certification specifying the exempt immunization(s). Diphtheria, Tetanus and Pertussis (DPT) Diphtheria and Tetanus and acellular Pertussis (DTaP) Polio (IPV or OPV) Haemophilus.

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