¨kdasdak’Bak´ VIPS – sMrab’ ¨BIsðèl

karbMeBj¨kdas KWtMrUveFÃIk~¬gry:eBl bYn q~Sm‘g

BtámanTak’Tg «f©/Ex VnbMeBjepÆIeTAsalaeron:_____________________________

(sUmsresry”agcºas’) «f©/Ex VnbMeBjepÆIeTAkariyal&y VIPS DI¨sæIK ___________________

manmuxgarCa VIPS sBëf©, EmneT? Emn eT

sMrab’sMnYrep§g@GMBI¨kdasdak’Bak´sMusµ&¨K KWKYrelIksYreTAkan’G~kcat’EcgkmµviFI VIPS enAtamsalaeron

eQµaH (___)___________________

¨tkUl eQµaHehA TUrs&Bæ #

GasydìanpæH ___________________

pÂèv elxpæH TI¨kug elx¨bcStMbn’

elxb&Nö ID manrUbftsMKal’xÂçn¨sbcºab’ minTan’hYs «f©/Ex (sUmKwbPØab’¨kdascmÂgb&NömanrUbftenaHmYysnÂwkmkpg)

(b&Nö ID ¨sbcºab’ KWmandUcCa: b&NöebIkbr É b&Nö ID k~¬grdì kalIhÃ&rj”a b&Nö Tahan É lixitqÂgEdn) (rUbft¨tUvmanKuNPaBbgúajmuxcºas’)

«f©/Ex kMeNIt: ___________________ GIuEm”l______________________________ TUrs&Bæ«d # __________________________

kmµviFIBiess: salaeron ________________ Intern: Emn eT Interns TSgGs’¨tUvkarpi‘tem«d eFÃIkicÍkarCamYysis§, EmneT? Emn eT

kmµviFIBiess: ______________________________

GÃIep§g:___________________________________

eQµaHsis§: _________________________________________ f~ak’TI: __________ eQµaH¨KU: ____________________________

eQµaHsis§: _________________________________________ f~ak’TI: __________ eQµaH¨KU: ____________________________

Btámanpæal’xÂçn etIG~kFÂab’maneraKrebg, EmneT? (minEmnkareFÃI Ets‘ Esºk) Emn eT ebIeqÂIyfa “Emn” … etIenAeBlNa?

etIG~kFÂab’VnTTYllTìplBIeraKrebgCa positive, EmneT? (PPD) Emn eT ebIeqÂIyfa “Emn” … etIenAeBlNa?

sUmKwbPØab’¨kdascmÂgbgúajlTìplGMBIeraKrebg É cemÂIyBI¨kdas TB Risk Assessment Questionnaire Certificate of Completion

mkCamYy¨kdasdak’Bak´ VIPS —

¨kdasbgúajlTìplGMBIeraKrebg KW tUvbJØak’ «f©/ExVneFÃI Ets‘ Esºk «f©/ExVnGanBinit´ lTìpl nig eQµaHmnæIreBT´ . etIG~kGaceFÃIkicÍkar edayminVc’e¨bICMnYyÓbkrNá, EmneT? Emn eT

enAeBlmanPaBGasn~ sUmTak’Tg: _____________________________ TUrs&Bæ #_________________ TUrs&Bæ«d #_________________

etIG~kkMBug É FÂab’VneFÃICa VIPS BImunmk, EmneT? Emn eT enAtamsalaeronNa? enAeBlNa? _________________ etIG~kFÂab’VneFÃICabuKðlikk~¬g¨ksYgGb’rM DI¨sæIK, EmneT? Emn eT ebIeqÂIyfa “Emn” … etIenAeBlNa? _________________________

etIG~kVneFÃIkarenAtamsalaeron É ¨ksYgmYyNa? _________________________________

karpi‘tem«d KWtMrUveFÃI sMrab’G~ksMus&µ¨K EdlnwgeFÃIkarenAmunem”agsis§cUleron nig bnæab’em”agsis§ecjBIeron . etIG~k … kalBIenAv&yekµgk‘I É Camnus§FMeTAehIykI‘ FÂab’VnTTYlkarCab’eTaskMhus cUl Kuk TTYlkarbg’¨Vk’Bin&y Cab’eQµaHk~¬gbJØI probation É Cab’eQµaHdak’ Kuk edaytulakar sIuvil É Tahan É FÂab’Vnyk¨Vk’eTAbg’«fÂFanaBItulakar, EmneT? Emn eT

etIG~kkMBugTTYlkartamcab’xÂçn edayminTan’maneBlkMNt’enAeLIy, EmneT? Emn eT

etIG~kkMBugCab’eQµaHk~¬gbJØI probation, EmneT? Emn eT ebIEmn, etIdl’eBlNa eTIbbJÍb’?______________________________________

ebIeqÂIyfa Emn … sUmsresrbgúajGMBIeTaskMhusTSgGs’enAEp~kxage¨kay¨kdasenH . sUmsresrbgúajpg ebIsinCamankartamcab’xÂçn EdlminTan’maneBl kMNt’enAeLIy . G~kk*¨tUvsresrbgúajeTaskMhustUctacGMBIEp~kebIkbrpgEdr (ebIsinCamankartamcab’xÂçn) dUcCa: ebIkbrTSg¨svwg nig karelIkElg[rYcxÂçn bnæab’ BIVnCab’eQµaHk~¬gbJØI probation puteTA CaedIm .

sUmeqÂIybMeBjenAEp~kxage¨kay

Revised: 08-19-17

OFFICE OF EQUITY, ACCESS, COLLEGE & CAREER READINESS Volunteers in Public Schools

sUmcMNSfa ebIsinCamankarbgúajeTaskMhusenAelI¨kdasdak’Bak´ KWcSVc’ ¨tUvman¨kdasBItulakar KwbPØab’mkCamYy¨kdasdak’Bak´enaH ehIyva¨tUvkareBlyUr bni‘csMrab’kareFÃItamdan . sMrab’sMnYrep§g@ sUmTak’TgG~k¨sI: Sharon Lazo-Nakamoto – (562) 997-8307

karBn´l’GMBIeTaskMhus sUmsresrbgúajenAEp~kxage¨kamGMBIeTaskMhus EdlG~kFÂab’VnTTYl . sUmsresrbgúajCa¨bePTcºab’ nig ¨bePTkMhus edayBn´l’ekºaHkºayGMBI «f©/Ex Vn Cab’eTaskMhus ¨bePTkMhus nig lTìpl¨tUvVnTTYl dUcCa: etIG~k¨tUvbg’¨Vk’Bin&y? Gs’cMnYnb”unµan? etIG~kVnCab’eQµaHk~¬gbJØI probation, EmneT? etIdl’eBl Na eTIbbJÍb’ É k*enAbn‘enAeLIy? rab’bJÍèlpgfa minTan’dwg ebIsinCaminTan’VnTTYldMNwgGÃIenAeLIy . sUmKwbPØab’¨kdasBItulakarmkCamYypg .

xÆM¬yl’fa BtámanbgúajenAelI¨kdasenH KWnwg¨tUvTTYlkarBinit´emIleLIgvij nig eFÃIkartamdany”agcºas’las’ edImºIbJØak’fa xÆM¬BitCaebkÅCn¨twm¨tUvEmn sMrab’karsMu sµ&¨KCYykicÍkarenAtamsalaeron«n¨ksYgGb’rM Long Beach Unified School District (LBUSD) . ebIsinCamankarrkeXIjcMNucNa EdlmineTog¨tg’ KWeQµaHrbs’xÆM¬ nwg¨tUvdkecjBIkarsMusµ¨&KCYykicÍkarenAtam¨ksYgGb’rM LBUSD .

edayVncMNayeBlbMeBj¨kdasdak’Bak´sMus&µ¨KCYykicÍkarenAtamsalaeron«n¨ksYgGb’rM LBUSD nig edaysarEtmaneKalbMNgbgúajGMBIbTBiesaFná nig lkÅN:ep§g@GMBIrUbxÆM¬ EdlmansmtÄPaBGacCYyeTAVn KWxÆM¬sUmp‘l’esckI‘GnuJïatGMBIkarbeJÍjBtámanTSgLayNa EdlG~kcg’dwgGMBIrUbxÆM¬ EdlxÆM¬VnelIk bgúajeTAkan’¨ksYgGb’rM LBUSD .

xÆM¬yl’fa eyagtamcºab’«n¨ksYgGb’rM DI¨sæIK KWxÆM¬¨tUvBak’b&Nö VIPS ID ¨Kb’eBl EdlxÆM¬enAk~¬gsalaeron . b&NöenHCakmµsiTiì«n¨ksYgGb’rM LBUSD nig ¨tUvrk§aTukenA k~¬gsalaeron¨Kb’eBl . xÆM¬yl’¨Bm edayminykb&NöeTApæH É [mnus§Nam~ak’xÍIBak’e¨bI . xÆM¬yl’¨BmsresreQµaHerogral’el Ik enAeBlxÆM¬cUlsalaeron nig enA eBlxÆM¬ecjeTApæHvij . xÆM¬nwgrk§aerOgsm©at’GMBIEp~keronsU¨t nig Gakbºkiriyarbs’sis§enAk~¬gf~ak’ EdlxÆM¬nwgcMNayeBlsµ¨&KCYy .

Senate Bill No. 791 – cºab’tMrUvcak’f~SbgûareraKenAk~¬grdì kalIhÃ&rj”a sMrab’mnus§FM EdleFÃIkarCamYyekµgtUc@ .

mkdl’ «f©TI1 ExkJïa 2016 KWbuKðlik nig G~ksMusµ&¨KTSgGs’ EdleFÃIkarCamYyekµg ¨BIsðèl ¨tUvbgúajlTìplcak’f~ak’bgûareraK k¨JØwl nig kíkman’ y”ag¨sbcºab’ . sMrab’karcak’f~aMbgûareraK ¨Kunp‘asayF©n’ EdlehAfa flu shot KWbuKðlik nig G~ksMus&µ¨KTSgGs’¨tUvTTYlkarcak’enAcenÂaH «f©TI1 sIha nig «f©TI1 F~è É bMeBj¨kdasGHGag min¨BmTTYlkarcak’f~Serogral’q~S . lTìplbJØak’GMBIkarKµaneraK rebg (TB) k*¨tUvbgúajpgEdr . Measles k¨JØwl:

«f©/Ex EdlVnTTYlkarcak’f~S ________________________

kareFÃI Ets‘ enA _____________ VnbJØak’GMBIPaBsSunwgeraKsBëf©enH .

Pertussis kíkman’: «f©/Ex EdlVnTTYlkarcak’f~aM ________________________

Influenza ¨Kunp ‘asayF©n’: «f©/Ex EdlVnTTYlkarcak’f~S ________________________

min¨BmTTYlkarcak’f~S ebImin¨BmTTYlkarcak’f~S KWsUmsresrbgúajmUlehtu: ___________________________________________________________________________________________________________

G~kCm©WVnTTYlelIkElgBIkarcak’f~S¨sbcºab’tMrUvenH edaymansuxPaBminlí É manbJúaTak’TgEp~kCm©Wep§g@eTot EdlnwgnSmkPaBe¨KaHf~ak’ .

eQµaHevCØbNëit nig kareVH¨taeQµaH

htÄelxa«nevCØbNëit

elxTUrs&Bæ

«f©/Ex:

eQµaH¨sbcºab’«nG~ksMusµ&¨K «f©/Ex

htÄelxa¨sbcºab’«nG~ksMusµ&¨K ___________________________________________ «f©/Ex _____________________________

----------------------------------------------------------------------------------------------------------------------------- ------------------------------------- FOR SCHOOL USE ONLY: KEEP COPY OF ALL DOCUMENTS ON FILE

Application reviewed by site VIPS Coordinator: __________________________ Date: _______________________________

Principal Signature: ___________________________________________________ Date: ______________________________

School _______________________________________________________________ Revised: 08-19-17

elx«n¨bePTcºab’ # ¨bePTeTaskMhus

«f©Ex VnekIteLIg

kEnÂgekItehtu

¨tUvVncUlCab’xÂçn É bg’¨Vk’Bin&y

Tuberculosis (TB) – eraK rebg:

«f©/Ex eFÃI Ets‘ TB: ____________________

«f©/Ex GanGMBIlTìpl TB:_____________________

Positive Negative

¨tUvft X-ray (ebIlTìplbgúajCa positive)

«f©/Ex ft X-ray: ___________ Positive Negative

«f©/Ex bMeBjkarsæg’vas’eraK TB: _________________