42-100.J Immunization


Table of Contents






Informing Requirements


Age Appropriate Immunization


Children Who Have Not Received Any Immunization In The First Year Of Life








Good Cause


Failure to Cooperate


Notice of Action (NOA)


Removing a Penalty


Immunization Acronyms and Abbreviations



42-100.J.1 Regulation



Parents and/or caretaker relatives are required to provide verification that all pre-school age children (under age six, unless a five year old child is enrolled in school) in the Assistance Unit (AU) have received age-appropriate immunizations. 


This requirement applies to all applicants and recipients of CalWORKs.


42-100.J.2 Informing Requirements







At intake, annual redetermination and when adding a child under the age of six, all CalWORKs applicants/recipients must be informed of the immunization requirements and the importance of having their child(ren) receive all necessary age-appropriate immunizations.  This can be accomplished by providing the CW 101 - CalWORKs Immunization Rules form.


The CW 101 must be included in all CalWORKs intake/renewal packets.


42-100.J.3 Age Appropriate Immunization





































Age appropriate immunizations for children under the age of six, and for children not immunized in the first year of life, are listed in the following two charts suggested by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians.


A child is considered to have received age-appropriate immunizations when the parent/caretaker relative has made a good faith effort to begin immunizations for the child, but the series cannot be completed at the time of verification due to spacing requirements between the doses in the series.


Immunizations currently recommended for children under the age of six.

Type of Shot


Recommended at Age

Polio (IPV)





2 months

4 months

6-18 months

Before starting school (4-6 years)

Diptheria, Tetanus, Pertussis (DTaP )






2 months

4 months

6 months

15-18 months

Before starting school (4-6 years)

Measles, Mumps, Rubella (MMR)



12-15 months

Before starting school (4-6 years)

Chickenpox (Varicella)


12-18 months

Hepatitis B




At birth – 3 months

1-5 months

6-18 months

Hemophilus influenzae Type b (Hib)




3rd or 4th

2 months

4 months

6 months (may not be required)

12-18 months (if any dose is given after 12 months, no further doses are needed)






2 months

4 months

6 months

12-15 months


42-100.J.4 Children Who Have Not Received Any Immunization In The First Year Of Life

The following are Immunizations recommended for children who have not received any immunizations in the first year of life. 


NOTE: A health care provider will determine appropriate immunizations when some, but not all, were received during the first year of life.




Immunization which may be given



First visit


·  Hepatitis B

·  DTaP

·  Hib

·  Polio (IPV)

·  MMP

·  Varicella

·  Pneumococcal (PCV)



Second visit

1-2 months after 1st visit

·  Hepatitis B

·  DTaP

·  Hib

·  Polio (IPV)

·  Pneumococcal (PCV)



Third visit

1-2 months after 2nd visit

·  DTaP

·  Polio (IPV)



Fourth visit

6 months after 3rd visit

·  Hepatitis B

·  DTaP



42-100.J.5 Kinrix™







Kinrix™ is a combined immunization and includes the Diphtheria, Tetanus and Acellular Pertussis (DTaP) and Inactivated Polio (IPV) immunizations in a single shot.  A child receiving Kinrix™ is considered to have received the DTaP and IPV immunizations.


Kinrix™ is given to children between the ages of four to six years old who need their booster doses of DTaP and IPV before they start kindergarten to protect them against Diphtheria, Tetanus, Pertussis, and Polio.


42-100.J.6 Verification

Verification of immunizations must be submitted at applications and renewals until the child completes all age-appropriate immunizations, or child reaches the age of six.








·  Must submit verification within 30 days from the date eligibility for Medi-Cal is granted (normally the same date CalWORKs is granted).

·  Those currently receiving Medi-Cal are required to submit verification within 45 days from the CalWORKs application date.




·  Must submit verification within 45 days from the annual renewal date.



Adding a Child

·  Children added to an existing AU must submit verification in accordance with the applicant time frames.



Inter-county transfer cases

·  For inter-county transfer cases, applicants/recipients are not required to resubmit duplicate verification of age-appropriate immunizations, when the first county has determined the verifications to be adequate.




















The following documents can be used to verify immunizations:

·         California Immunization Card (Yellow Card)

·         Immunization Verification Form (CSF 49).


California Immunization Record (Yellow Card)

The California Immunization Record (Yellow Card) is the primary document used to verify immunizations.


Immunization Verification Form (CSF 49)

The Immunization Verification Form (CSF 49) is used to verify age-appropriate immunizations when the yellow card is not available or does not verify age-appropriate immunizations.  The CSF 49 must be completed and signed by:

·         A medical provider (i.e. physician, authorized member of physician’s staff, public health department, etc.), or

·         A public agency which requires age-appropriate immunizations (i.e. local school district, the Head Start Program, licensed day care center, etc.).


42-100.J.7 Exemptions

The immunization requirement does not apply if the parent/caretaker relative submits the following:

·         Written statement from a physician or health professional working under the supervision of the physician, indicating that the child should not be immunized for medical reasons.  This statement must include a description of the medical condition and the duration, or

·         Affidavit that the immunization requirement is contrary to the applicant/recipient’s religious or personal beliefs.


Note:  The CSF 49 may be used to verify an exemption due to medical reasons.  When used to verify an exemption due to medical reasons, it must be signed by a medical provider.  These statements must be kept in the case file.


42-100.J.8 Good Cause
















Good cause for failure to submit verification may be determined in, but is not limited to the following circumstances:

·         Lack of reasonable access to immunization services:

o   The child does not currently have Medi-Cal;

o   There is not nearby public clinic which offers free immunizations;

o   The family does not have adequate transportation.

·         The child is too sick to receive immunizations:

o   The parent(s)/caretaker relative or the child was sick and could not go to the doctor.

·         The parent(s)/caretaker relative could not get a timely appointment with the doctor;

·         The immunization the child needed was not available;

·         The records do not correctly show all the immunizations the children received and the caretaker relative is trying to correct the records; and

·         Language barriers.


The Human Services Specialists (HSS) will not impose a penalty. The parent(s)/caretaker relative will be given an additional 30 days to submit immunization verification. HSSs are required to assist the parent(s)/caretaker relative in obtaining necessary verification of immunizations.


42-100.J.9 Failure to Cooperate

When an AU fails to provide the required immunization verification, the HSS must first determine whether good cause exists.


If yes

If no

Deadline shall be extended an additional 30 days as specified in section CPG 42-100.J.8

The parents are considered non-cooperative with the immunization requirement.


Their needs are not considered for both financial eligibility and grant computation.


Any non-exempt income the penalized parent(s)/caretaker relative receives is counted in the family’s income calculation.










·         If both parents are in the AU, the both parents must have the penalty applied.

·         In a minor parent case, the aided senior parent is considered the responsible caretaker relative and is therefore penalized if age-appropriate immunizations are not verified for the minor parent’s child.


42-100.J.10 Notice of Action (NOA)

HSSs are required to use M40-105C NOA to:

·         Specify which child is not current in their shot records or lacks proof of up-to-date immunizations;

·         List possible good cause reasons;

·         Explain why a penalty would apply; and

·         Tell clients how and when cash aid would be restored to the assistant unit.


42-100.J.11 Removing a Penalty

As specified in section CPG 40-125.A.2, the penalized parent(s)/caretaker relative(s) will be added back to the AU, effective the first of the following month in which:

·         Documentation is submitted verifying all age appropriate immunizations have been received by the child,

·         A good faith effort has been made,

·         An exemptions is met, or

·         The child turns six years of age.


42-100.J.12 Immunization Acronyms and Abbreviations











Immunization names are often abbreviated and the abbreviations may differ for some of the immunizations.


A Vaccine Acronyms and Abbreviations chart is available in CPG 45-200 Resources and Desk Aids to be used as reference.


The chart contains common acronyms and abbreviations used by both the Centers for Disease Control and Prevention (CDC) and the California Immunization Registry (CAIR) for widely used immunizations.


The most recent version of CDC’s list can also be found at the following link: