Immunization Data Entry Worksheet
School Year:  2012-2013
Disease Category Protected and in Compliance Religious Objection Medical Reason or Objection Approved Schedule Unprotected and in Noncompliance                        (include transfer students without records)
Prekindergarten
Polio          
DTP/DTaP/Td          
Measles          
Rubella          
Mumps          
Hepatitis B          
Hib          
Varicella/Chickenpox          
Kindergarten
Polio 23 4 0 0 2
DTP/DTaP/Td 23 4 0 0 2
Measles 22 4 0 0 3
Rubella 22 4 0 0 3
Mumps 22 4 0 0 3
Varicella/Chickenpox 23 4 0 0 2
Grade 1
Polio 38 2 0 0 0
DTP/DTaP/Td 38 2 0 0 0
Measles 38 2 0 0 0
Rubella 38 2 0 0 0
Mumps 38 2 0 0 0
Varicella/Chickenpox 38 2 0 0 0
Grade 2
Polio 30 5 0 0 0
DTP/DTaP/Td 30 5 0 0 0
Measles 30 5 0 0 0
Rubella 30 5 0 0 0
Mumps 30 5 0 0 0
Varicella/Chickenpox 30 5 0 0 0
Disease Category Protected and in Compliance Religious Objection Medical Reason or Objection Approved Schedule Unprotected and in Noncompliance                        (include transfer students without records)
Grade 3
Polio 27 3 0 0 0
DTP/DTaP/Td   27 3 0 0 0
Measles 27 3 0 0 0
Rubella 27 3 0 0 0
Mumps 27 3 0 0 0
Varicella/Chickenpox 27 3 0 0 0
Grade 4
Polio 23 3 0 0 0
DTP/DTaP/Td 23 3 0 0 0
Measles 23 3 0 0 0
Rubella 23 3 0 0 0
Mumps 23 3 0 0 0
Varicella/Chickenpox 23 3 0 0 0
Grade 5
Polio 33 3 0 0 0
DTP/DTaP/Td   33 3 0 0 0
Measles 33 3 0 0 0
Rubella 33 3 0 0 0
Mumps 33 3 0 0 0
Hepatitis B 33 3 0 0 0
Varicella/Chickenpox 33 3 0 0 0
Grade 6
Polio 34 1 0 0 0
DTP/DTaP/Td 34 1 0 0 0
Tdap 34 1 0 0 0
Measles 34 1 0 0 0
Rubella 34 1 0 0 0
Mumps 34 1 0 0 0
Hepatitis B 34 1 0 0 0
Varicella/Chickenpox 34 1 0 0 0
Disease Category Protected and in Compliance Religious Objection Medical Reason or Objection Approved Schedule Unprotected and in Noncompliance                        (include transfer students without records)
Grade 7
Polio 37 1 0 0 0
DTP/DTaP/Td 37 1 0 0 0
Measles 37 1 0 0 0
Rubella 37 1 0 0 0
Mumps 37 1 0 0 0
Hepatitis B 37 1 0 0 0
Varicella/Chickenpox 37 1 0 0 0
Grade 8
Polio 28 6 0 0 0
DTP/DTaP/Td 28 6 0 0 0
Measles 28 6 0 0 0
Rubella 28 6 0 0 0
Mumps 28 6 0 0 0
Hepatitis B 28 6 0 0 0
Varicella/Chickenpox 28 6 0 0 0
Grade 9
Polio 33 4 0 0 0
DTP/DTaP/Td 33 4 0 0 0
Tdap 31 4 0 0 2
Measles 33 4 0 0 0
Rubella 33 4 0 0 0
Mumps 33 4 0 0 0
Hepatitis B 33 4 0 0 0
Varicella/Chickenpox 33 4 0 0 0
Disease Category Protected and in Compliance Religious Objection Medical Reason or Objection Approved Schedule Unprotected and in Noncompliance                        (include transfer students without records)
Grade 10
Polio 30 1 0 0 0
DTP/DTaP/Td 30 1 0 0 0
Measles 30 1 0 0 0
Rubella 30 1 0 0 0
Mumps 30 1 0 0 0
Hepatitis B 30 1 0 0 0
Varicella/Chickenpox 30 1 0 0 0
Grade 11
Polio 26 2 0 0 0
DTP/DTaP/Td 26 2 0 0 0
Measles 26 2 0 0 0
Rubella 26 2 0 0 0
Mumps 26 2 0 0 0
Hepatitis B 26 2 0 0 0
Grade 12
Polio 21 0 0 0 0
DTP/DTaP/Td 21 0 0 0 0
Measles 21 0 0 0 0
Rubella 21 0 0 0 0
Mumps 21 0 0 0 0
Hepatitis B 21 0 0 0 0
 
Total Counts    PreK–Grade 12          
Actual unduplicated count of students who are unprotected and in noncompliance with immunization requirements.                                                                 Count students only once, even if they are noncompliant in more than one disease category.                                                                                                       They may also need a physical examination.
PreK K 1 2 3 4 5 6 7 8 9 10 11 12
  3                 2      
Total number of students who are in noncompliance with the physical exam requirement ONLY.                                                                                                       Do NOT include any student counted in the actual unduplicated count of students in the row above.
PreK K 1 2 3 4 5 6 7 8 9 10 11 12
  1               1 2      
Total number of students who were excluded from school on October 15, or an earlier established exclusion date, for not being in compliance.  Report students excluded for one or more days.
PreK K 1 2 3 4 5 6 7 8 9 10 11 12
  4                 3