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Program Annual Reports and Progress Assessments

School Vaccination Coverage
for Kindergarten and Middle School

Consolidated Summary for School Year 2010-11

This page is READ-ONLY. You cannot edit or save data entered on this page. You must use the individual survey pages.

Grantee Project Area: 

report and contact update

1. Confirm reporting intentions.
Please select one:
2. Update School contact information.

Primary Contact
 
name: Title:
Phone: Ext:  Email:
Fax:
 
Emails to the primary contact should cc:
 
name:
Phone Ext:  Email:
Fax
3. Provide Preparer information.
Preparer information
 
Name: Title:
 
Phone: Ext: Email:
 

section i: scope of the report

grantee report data

School Year
Program Manager

scope of the report

1. School Survey Methodology
Type of SchoolSchools Surveyed
Kindergarten
Public
Private
Middle School
Public
Private
2. Children Surveyed Methodology
Type of SchoolChildren Surveyed
Kindergarten
Public
Private
Middle School
Public
Private

2A. If you utilized a survey to complete the school vaccination coverage assessment for 2009-10, was the survey strategy approved by CDC? Answered random sample or Not a random sample to either Q1 or Q2

3. Do you use survey results for a retrospective analysis? (Retrospective means using the data to look at coverage when the children were younger, i.e. 2 years old.)


4. How were the data for this report collected?






Describe training: 

4A. If the data were self-reports by schools, how were the results validated by the health department?



  Explanation: 

4B. Were the results of your self-reported school survey consistent with the results of the validation (within the confidence interval of the sample)?To be answered if response to Q4A was option 2 or 3.



4C. Who will be sending the validation data (Excel file and variable description) to CDC's technical assistance link?Technical Assistance link
name
Phone
Email

5. What is the source of the child's vaccination information in the school record? Check all that apply.





Number of kids with shot card's NOT signed by a provider: 
Why not signed?


6. What immunization information is included in the student's record? Check all that apply
Vaccine/antigen:Check all that apply















7. What immunization information does the health department receive? Check all that apply
 
Vaccine/antigen:Check all that apply















8. Do you have a grace period (i.e. 14 days) for students who are not up-to-date?

 # of days...999 = Unofficial/unlimited grace period

9. The vaccination data for this report represents vaccination rates:


-- When? 

10. What process is used to determine up-to-date status? (check one)



 

Please select "Final" when you have completed all data entry for the School Scope of Report section.
 

section ii: kindergarten

enrollment

Please fill in the blank with the appropriate numbers. (You can get information on school enrollment from your department of education.)

 
11. What is the total number of schools in that have kindergartens?
a. Public:
b. Private:
 

12. How many of the schools had data included in this report?
a. Public:
b. Private:
 

13. What is the total number of children enrolled in all kindergartens in ?
a. Public:
b. Private:
 

14. How many kindergartners did you survey? (This should include children with a missing vaccination record.)
a. Public:
b. Private:
 

15. How many surveyed kindergarten children did not have a vaccination record?
a. Public:
b. Private:
 
15a. What happens to these children?
i. Public: (Check all that apply)



 
ii. Private: (Check all that apply)



 

exemptions

Instructions for completing the exemption section: Please report permanent exemptions and temporary exemptions separately. If you are unable to do that, please use the spaces for permanent exemptions to report total exemptions in each category. Make a note in the comment section explaining how you reported the exemption data.
           
 
Type of Exemption Is this type of exemption allowed? Do you/can you track this type of exemption? Number of surveyed children who were exempt.
Public Private
 
16. Medical
17. Religious
18. Philosophical
19. Temporary
 
 

20. Comments regarding kindergarten exemptions:


vaccine information for kindergarten (required)

  • Comments and definitions on reporting vaccine requirements and doses:
  • Up-to-date(UTD) = received the appropriate doses of each vaccine.
  • Include a vaccine in your count whether it was administered individually or through combination vaccines.
               
 
Vaccine (doses for complete series) # Doses for UTD status in your state. Number of surveyed children meeting state rqmts. ACIP Recommended Doses Number of surveyed children UTD on complete series.
Public Private Public Private
 
21. Polio (3+)
22. Diphtheria (4+)
23. Tetanus (4+)
24. Pertussis (4+)
25. MMR (2)
26. Hepatitis B (Hep B) (3+)
27. Varicella (2)
28. Influenza
 
29. How many schools in your state have reported MMR 2 dose coverage in the following ranges?
 
  Coverage Range # of Schools  
 
  95% or above:  
  90-94%:  
  80%-89%:  
  <80%:  
  Unknown:  
 
30. Vaccine related comments

Please select "Final" when you have completed all data entry for the Kindergarten section.
 

section iii: middle school

enrollment

Please fill in the blank with the appropriate numbers. (You can get information on school enrollment from your department of education.)
 
31. Please check each grade that you survey in Middle School:
a. Public:
b. Private:
 

 
32. What is the total number of schools in that have any of the middle school grades listed in Q31?
a. Public:
b. Private:

33. How many of the schools in Q32 had data included in this report?
a. Public:
b. Private:


34. What is the total number of children in that are enrolled in any of the middle school grades listed in Q31?
a. Public:  6th Grade 7th Grade 8th Grade
b. Private:  6th Grade 7th Grade 8th Grade


35. How many middle school children did you survey? (This should include children with a missing vaccination record.)
a. Public:  6th Grade 7th Grade 8th Grade
b. Private:  6th Grade 7th Grade 8th Grade


36. How many surveyed middle school children did not have a vaccination record?
a. Public:
b. Private:
 
36a. What happens to these children?
i. Public: (Check all that apply)



 
ii. Private: (Check all that apply)



 

exemptions

Instructions for completing the exemption section: Please report permanent exemptions and temporary exemptions separately. If you are unable to do that, please use the spaces for permanent exemptions to report total exemptions in each category. Make a note in the comment section explaining how you reported the exemption data.
           
 
Type of Exemption Is this type of exemption allowed? Do you/can you track this type of exemption? Number of surveyed children who were exempt.
Public Private
 
37. Medical
38. Religious
39. Philosophical
40. Temporary
 

41. Comments regarding middle school exemptions:


vaccine information for middle school (recommended)

 
  • Comments and definitions on reporting vaccine requirements and doses:
  • Up-to-date (UTD) = received the appropriate doses of each vaccine.
  • Include a vaccine in your count whether it was administered individually or through combination vaccines.
 
Data for the 6th Grade
               
 
 
Vaccine (doses for complete series) # Doses for UTD status in your state. Number of surveyed children meeting state rqmts. ACIP recommended doses Number of surveyed children UTD on complete series.
Public Private Public Private
 
42a. Hepatitis B Series
43a. MMR
44a. Varicella
45a. Meningococcal (MCV-4)
46a. Human Papillomavirus (HPV)
47a. Booster Tdap
 

Comments: 
 
 

Data for the 7th Grade
               
 
 
Vaccine (doses for complete series) # Doses for UTD status in your state. Number of surveyed children meeting state rqmts. ACIP recommended doses Number of surveyed children UTD on complete series.
Public Private Public Private
 
42b. Hepatitis B Series
43b. MMR
44b. Varicella
45b. Meningococcal (MCV-4)
46b. Human Papillomavirus (HPV)
47b. Booster Tdap
 

Comments: 
 

Data for the 8th Grade
               
 
 
Vaccine (doses for complete series) # Doses for UTD status in your state. Number of surveyed children meeting state rqmts. ACIP recommended doses Number of surveyed children UTD on complete series.
Public Private Public Private
 
42c. Hepatitis B Series
43c. MMR
44c. Varicella
45c. Meningococcal (MCV-4)
46c. Human Papillomavirus (HPV)
47c. Booster Tdap
 

Comments: 
 
 
 
48. Vaccine related comments

Please select "Final" when you have completed all data entry for the Middle School section.
 

section iv: immunization laws and requirements

college requirements

49. Does your project have college vaccination mandates or requirements for the following vaccines?
 
Hepatitis B
Human papillomavirus
MMR2
Meningococcal conjugate
Tdap
Td
Varicella

50. If you have college vaccine requirements that are not listed above or have additional comments about college vaccine requirements, please include them below
Comments: 

immunization laws and requirements for school and child care entry

51. Are private schools obligated to conform to the vaccination laws and requirements?
 


 

 

 
52. If a home-schooled child participates in school sponsored activities (e.g., field trips, clubs, or sports), are they required to have vaccinations that match school requirements prior to participating?
 




  Reasons/Explain give examples 
 

53. Have there been any changes to the immunization requirements or laws for school or child care entry during the present school year?
 



54. Additional Comments


Please select "Final" when you have completed all data entry for this section.
 
 
(If you answer "In-process", CDC's records will indicate that you have not completed your report. Please remember to update this page and check "Final" when you are done.)

Safer, Healthier People
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