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School Immunization Survey

Return To:
Fall 2018 Due Date: November 16
CT Dept. of Public Health
Immunization Program PHONE: 860 509-7929
410 Capitol Ave. MS# 11MUN FAX: 860 707-1941
P.O. Box 340308 Hartford, CT 06134-0308

NAME OF SCHOOL NAME OF DISTRICT (If Applicable) SCHOOL ADDRESS/TOWN/ZIP CODE

TOTAL ENROLLMENT IN SCHOOL ELEMENTARY / SECONDARY PUBLIC / NON-PUBLIC TELEPHONE NUMBER AT SCHOOL
(CIRCLE ONE) (CIRCLE ONE)
PLEASE PRINT I certify this survey to be complete and accurate to the best of my knowledge
PERSON COMPLETING SURVEY SIGNATURE CERTIFICATION: DATE SURVEY COMPLETED

This page asks for the immunization status of all Pre-kindergarten, Kindergarten and 7th grade Required Vaccines (K and 7th Grade):
students as of October 1st.
DTP, DTaP, DTaP-IPV, DT, Td, DTaP-IPV-Hib, DTaP-
Part A. Exemptions Pre-K K 7th Grade IPV-HepB: 4 doses with one dose after age 4
Polio (OPV or IPV): 3 doses with one dose after age 4
Total number of students Measles, Mumps and Rubella (MMR): 2 doses, the first
dose on or after the 1st birthday and separated by at
Religious least 28 days, or laboratory confirmed immunity
Exemption
Medical Varicella: 2 doses, the first dose on or after the 1st
birthday, prior history of disease, or laboratory confirmed
Subtotal of students Hep B : 3 doses
Hep A: 2 doses administered 6 calendar months apart
* Part B. Vaccine Series A NC A NC A NC for all children born on 1/1/2007 or later

Diphtheria, tetanus, and Required Vaccines (7th Grade Only):


pertussis-containing vaccines Tdap: 1 dose Meningococcal: 1 dose
Polio Required Vaccines (Pre-K)
4 DTP, 3 Polio, 1 MMR, 3 Hep B, 1 Varicella, 1 PCV, 1
MMR Hib and 2 doses of Hep A vaccines.
Varicella Reminders:
For the 2018-19 school year all students K through
Hep B grade 12 are required to have 2 doses of varicella
vaccine or documented immunity; all students grades 7
Hep A through 12 are required to have 1 dose of Tdap and 1
dose of meningococcal vaccines.
Tdap

Meningococcal

**Subtotal of Students
receiving all required vaccines
Definitions:
Exemptions: medical or religious exemptions must be part of the student's file. Medical exemptions must be consistent with national guidelines. If a student
has an exemption, do not count them in any other category except religious or medical exemption even if they have received previous immunizations.
Subtotal of students = Number of students minus exemptions (both religious and medical).
Adequately Immunized (A): this category applies to those children who have received the minimum number of doses of each vaccine appropriate for the
grade level. Non-Compliant (NC): does not meet adequately immunized requirements.
*A + NC for each row should equal the subtotal for each grade in Part A (students with exemptions are not counted in Part B).
** Of the subtotal, A=students who have completed ALL required vaccines for the grade level indicated, NC=students who have NOT completed ALL
required vaccines.

Part C. Exemption information for all other grade levels


1st 2nd 3rd 4th 5th 6th 8th 9th 10th 11th 12th
Total number of
students
Medical
Exemption Religious