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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
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
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.