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Immunization Good Cause Request Form

The document is an Immunization Good Cause Request Form for CalWORKs clients in California, requiring proof of immunizations for children under six. If clients have valid reasons for not immunizing, they can request an exemption by filling out the form and indicating the reason. The form includes a list of acceptable reasons for exemption and requires client and worker signatures.

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109 views1 page

Immunization Good Cause Request Form

The document is an Immunization Good Cause Request Form for CalWORKs clients in California, requiring proof of immunizations for children under six. If clients have valid reasons for not immunizing, they can request an exemption by filling out the form and indicating the reason. The form includes a list of acceptable reasons for exemption and requires client and worker signatures.

Uploaded by

puneet.lakhina85
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

IMMUNIZATION GOOD CAUSE REQUEST FORM

CLIENT NAME CASE NUMBER DATE


Rachele Eschenburg 2206861 Apr 21, 2025

All children on your CalWORKs grant who are under the age of six must have up-to-date immunizations.
These are shots or vaccines. You must give us proof of the immunizations. If you have a good reason for not
immunizing your child(ren), you do not have to have this proof. This is called “good cause.”

List the child(ren) you are requesting good cause for:

Mikeyla

Instructions: If you have a good reason for not immunizing your child(ren), fill out this form and indicate which
child that you are claiming a “good cause” exemption for by placing the circled number below next to the name
of each child listed above. Make a copy of the form for you to keep and mail or take the form back to your
worker.

Circle the number that applies to each child listed above:

1. You do not believe in immunizing your child(ren).

2. The doctor said that your child(ren) should not be immunized. You will need to give us a statement
from the doctor’s office.

3. You could not get the immunizations because of transportation problems.

4. You could not get an appointment to get the immunizations.

5. The immunization your child(ren) needed was not available.

6. The doctor does not speak your language or there was another language access problem.

7. You or the child(ren) were sick and could not go to the doctor.

8. The records do not correctly show all the immunizations your child(ren) got and you are trying to correct the
records. You will need to show us the corrected records.

9. You have other good cause reason, which is .

I declare under penalty of perjury that the above statement(s) is true.

CLIENT SIGNATURE DATE PHONE

WORKER’S NAME DATE PHONE

CW 2209 (12/14) REQUIRED - SUBSTITUTES PERMITTED

0000000603255060

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