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    Kindergarten Worksheet

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    JayRAj
    The document is a kindergarten immunization survey worksheet that is not to be returned to the state health department. It provides instructions for school staff to record the number of vaccine doses each student has received for different diseases. Keeping the completed worksheet will help identify students who are not fully vaccinated in the event of a disease outbreak at the school.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Kindergarten Worksheet

    Uploaded by

    JayRAj
    386 views2 pages
    The document is a kindergarten immunization survey worksheet that is not to be returned to the state health department. It provides instructions for school staff to record the number of vaccine doses each student has received for different diseases. Keeping the completed worksheet will help identify students who are not fully vaccinated in the event of a disease outbreak at the school.

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    The document is a kindergarten immunization survey worksheet that is not to be returned to the state health department. It provides instructions for school staff to record the number of vaccine doses each student has received for different diseases. Keeping the completed worksheet will help identify students who are not fully vaccinated in the event of a disease outbreak at the school.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    386 views2 pages

    Kindergarten Worksheet

    Uploaded by

    JayRAj
    The document is a kindergarten immunization survey worksheet that is not to be returned to the state health department. It provides instructions for school staff to record the number of vaccine doses each student has received for different diseases. Keeping the completed worksheet will help identify students who are not fully vaccinated in the event of a disease outbreak at the school.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    KEEP THIS WORKSHEET FOR YOUR OWN RECORDS.

    DO NOT RETURN TO MDPH.

    KINDERGARTEN IMMUNIZATION SURVEY WORKSHEET


    (Do Not Send to State)
    For each child, please record (in the appropriate column) the total number of vaccine doses received. Please mark only one box for each vaccine. Keep this worksheet as a summary of childrens immunization
    records. In the event of a case of a vaccine-preventable disease at your school, this worksheet will help you identify which children are not fully immunized. Make a copy of this blank form for recording the
    immunization status of children entering your school after the survey has been completed.
    Name
    Birth
    DTaP/DTP1
    Polio2
    MMR3
    Hepatitis B
    Varicella4
    5-4-2-3-2
    Flu6
    5
    Date
    series
    1 2 3 4 5 M7 R8
    1
    2
    3
    4 M7 R8
    1
    2 M7 R8
    1
    2
    3
    M7 R8
    1
    2 Disease M7 R8
    >1

    Hep A

    TOTAL
    DTaP/DTP
    1

    Polio

    MMR

    Hep B

    Varicella

    DTaP: Diphtheria, tetanus, and acellular pertussis. DTP: Diphtheria, tetanus, and pertussis. Do not count DT (diphtheria/tetanus).
    2
    Polio: eIPV or IPV (Salk), OPV (Sabin).
    3
    MMR: Measles, mumps, rubella (do not count doses given 5 days before first birthday or second dose if it was given <28 days after the first dose).
    4
    Varicella: two doses of varicella vaccine (do not count doses given 5 days before first birthday or second dose if it was given <28 days after the first dose) or a physician-certified reliable history of chickenpox disease.
    5
    5-4-2-3-2 series: 5 DTaP/DTP and 4 polio and 2 MMR and 3 hepatitis B and 2 varicella (all vaccines required for school entry).
    If child has history of disease and only 1 dose of varicella vaccine, count under disease. If a child has history of disease and 2 doses of varicella vaccine, count under vaccinated.
    6
    Influenza: one or more doses of seasonal influenza vaccine received between July 2013 and June 2014.
    7
    M: Medical Exemption 8 R: Religious Exemption

    5-4-2-3-2

    Flu

    Hep A

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