Form Dhhs 2900A PDF Details

Form dhhs 2900A is a form that is used to report child abuse. It is important that this form be filled out accurately and promptly so that children can receive the necessary assistance. This form can be filled out by anyone who has reasonable suspicion of child abuse. Details about the abuse, as well as the identity of the perpetrator, should be included on the form. Filing a false report of child abuse can result in criminal charges.

Form NameForm Dhhs 2900A
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesdhhs 2900a, Hib, PCV7, DHHS

Form Preview Example


Name of Child Care Facility__________________________________________________________________________________Phone___________________________________

Street Address (not P.O. Box)___________________________________________City_____________Zip__________ County____________________________________________

EMAIL ADDRESS:_ __ _ Operator______________________________ Facility License Number____________________________

(if you have an email to provide)

Total Number of Children enrolled:_____________ Total Number of Children without a shot record: ____________

Name of child

Date of




on file?

(yes or no)



on file?

(yes or no)

# of

# of





and DT








#of Hib doses

And Date of

last dose




on or


age one





# of


# of


# of







Hep B


doses or

(not a




date of

















# of Hep A

(not a

required vaccine)

According to state law, state or local health officials may inspect your records any time during normal business hours.

This report is true and accurate. __________________________________________________________ ______________________ _____________________________________________

(Please sign and date each page)

Signature of Operator/Owner


Person Preparing Report

North Carolina Department of Health and Human Services



Division of Public Health, Women’s and Children’s Health Section


DHHS 2900A (Revised 08/11)




Immunization Branch • 1917 Mail Service Center • Raleigh, NC 27699-1917919-707-5550


Immunization (Review 06/12)

Mail the white copy to:

Purpose: To provide child care operators with a means of fulfilling their legal obligations to assure that all children are properly immunized. This form is required by North Carolina Law (G.S. 130A-155) and is used for yearly statistical analysis.

Instructions: (Review the enclosed handout “Children in Child Care – What SHOTS Do They Need”? before completing this report.)

Note: If you have a system for tracking immunizations at your center and can provide a computer printout that includes the same information as listed on this form, you can submit that printout instead of completing this form. The printout must be signed by the Operator. The printout must be mailed to the Immunization Branch and your local health department.

Complete and mail this report by December 1. Press firmly to assure that all copies are readable. Complete the top portion of this form by filling in your facility information. Include facility license number. If your center is closed, please write closed across the form and mail it to the Immunization Branch

If your center has no children enrolled, please write zero in the total enrollment line and mail in the form.

For each child in your facility, enter their first name, their last name and their date of birth. Initials are not acceptable. You do not need to include school aged children who are enrolled in school.

For children with medical or religious exemptions on file enter ‘YES’ in the appropriate column.

Medical Exemption: A doctor licensed to practice medicine in NC must sign, date, and put in writing that a specific immunization is or may be harmful to a child’s health for a specific reason. Medical exemption statements are required by law to be on file at the facility and should state how long the exemption will last.

Religious Exemption: Parents who claim a religious objection to immunizations must provide to the facility a signed, dated statement indicating that receiving immunizations is against their bona fide religious beliefs. Religious Exemption Statements are required by law to be on file at the facility.

Enter the total number of doses of each vaccine the child has received.

The last two vaccines listed in the chart (PCV7 or Prevnar and Hep A) are recommended vaccines and not required vaccines for children in child care to have. If the child has received doses of these vaccines, please put the number of doses in the appropriate box, if they have not received any Prevnar or Hep A, you can put a zero or leave blank.

The operator and the person completing the report must sign and date it. Unsigned reports will be returned for signature. As soon as you have completed this report:

Immunization Branch

NC Department of Health and Human Services Division of Public Health

1917 Mail Service Center

Raleigh, NC 27699-1917

Mail the yellow copy to: Your Local Health Department Immunization Program

Keep the pink copy for your records.