Form F 04002 PDF Details

Ensuring the health and safety of students in schools is paramount, and the F 04002 form plays a crucial role in this endeavor. Under the directive of the Wisconsin Department of Health Services, schools are tasked with the responsibility to report the vaccination status of their students through grade 12 to the local health department. This measure, as mandated by Wisconsin State Statute 252.04, ensures that all students, barring those with appropriate waivers, provide evidence of immunization against multiple diseases within specific timelines following their admission. The form not only requires schools to keep track of the vaccination progress including the first and subsequent doses of vaccines such as DTP/DTaP/DT/Td, Polio, MMR, Hepatitis B, and Varicella but also to report non-compliance by the 40th school day each year. Furthermore, it segments students into categories based on their vaccination status or waiver presence, mandating detailed follow-up for those behind schedule or with no records. The intricate structuring of this form demonstrates a comprehensive approach to public health within the educational system, facilitating a coordinated effort between schools and health departments to prevent outbreaks of vaccine-preventable diseases. With sections designed for detailed listings of student data, the F 04002 form embodies a critical aspect of school administrative duties, promoting a health-conscious environment conducive to educational success.

QuestionAnswer
Form NameForm F 04002
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesf 04002, F-04002B, 40th, F-04002

Form Preview Example

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

s. 252.04, Wis. Stats.

F-04002 (Rev. 08/08)

 

SCHOOL REPORT TO LOCAL HEALTH DEPARTMENT

Wisconsin State Statute 252.04 requires that all students through grade 12 who do not submit waivers must present evidence of having received at least the first dose of each vaccine required for their grade within 30 school days of admission and the second dose of DTP/DTaP/DT/Td, Polio, MMR, Hepatitis B and varicella vaccines within 90 school days of admission. Evidence of the third and fourth doses (if required for their grade) of DTP/DTaP/DT/Td, Polio and the third dose of Hepatitis B vaccines must be submitted within 30 school days of the beginning of the next school year. Schools must report to the local health department the compliance by students each year by the 40th school day.

Telephone

I.D. Number for Address Label

School District

Principal

Person Completing Form

Name of School (as listed on label)

Address

City/Town

Zip

County

COMPLETE BOTH PARTS A AND PART B (Part B is F-04002B page 2)

PART A

INSTRUCTIONS: Indicate how many students fall into each category (1 through 7) in the grade groupings below. The sum of these categories (row 8) must equal the enrollment for the grade(s) in that column. List students in rows 2 through 7 in Part B. Mail to your local city or county health department, not the Wisconsin Department of Health Services. Do not delay completion of this report, submit promptly.

(1)

(2)

(3)*

(4)*

(5)

(6)

(7)

(8)**

List Number of Students

Pre-Kindergarten Kindergarten Grades 1-12

TOTAL

Who meet all minimum requirements

IN PROCESS (first dose within 30 school days and second dose within 90 school days)

BEHIND SCHEDULE (missed deadline for first, second, or final doses of vaccine)

With NO RECORD on file

With health WAIVER

With religious WAIVER

With personal conviction WAIVER

TOTAL (must = enrollment for grades included in the column)

*Names of these students are to be reported to the district attorney and/or may be excluded. **Total Row 8 = Total of Last Column = Enrollment of School

F-04002 (Rev. 08/08)

PART B

Page 2

Instructions: List all students from Part A, rows 2 through 7 in ascending grade order. Include date of birth, grade level, and vaccine(s) received to date. Enter “0” if no vaccine was received. Use extra sheets if necessary.

•For student(s) BEHIND SCHEDULE or NO RECORD (Part A, rows 3 & 4) enter date student(s) will be reported to the District Attorney.

•For student(s) IN PROCESS or WAIVERS (Part A, rows 2,5,6 & 7) check appropriate box, ‘In Process’, H=Health Reasons, R=Religious Reasons, and PC=Personal Conviction. Under Varicella indicate total doses received or “D” for disease. Note: If a separate list is maintained of students who are IN PROCESS of receiving only Varicella vaccine and/or BEHIND SCHEDULE in receiving only Tdap vaccine, it is not necessary to list these students on Part B.

•For MMR, if first dose was received before the student’s first birthday, do not count the dose. Do not include a history of disease, only the vaccine.

Name

Date of

Birth

 

 

Non-Compliant /

 

Mark (X)

 

 

DTP / DTaP / DT / Td

 

Polio

Hep B

MMR

Varicella

 

 

 

Report to District Attorney

 

 

 

Tdap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Admission

 

Behind

No

 

In

H

R

P

 

Total

Last

Total

 

Last

Total

Total

Total Doses

Dose

To WI

Grade

Schedule

Record

 

Process

 

 

 

 

C

 

Doses

Dose

Doses

 

Dose

Doses

Doses

or

Date

School

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

Date

 

 

D=Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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1. It is critical to fill out the HHealth correctly, so be careful while filling in the parts including all these blank fields:

Td writing process described (step 1)

2. Soon after this part is filled out, proceed to type in the relevant information in all these: DTaPDTPDTTd, a Meets minimum requirements, b In process, c Behind schedule, d Health waiver, e Religious waiver, f Personal conviction waiver, g No record, Polio, a Meets minimum requirements, b In process, c Behind schedule, d Health waiver, e Religious waiver, and f Personal conviction waiver.

Td conclusion process described (part 2)

3. The following section is mostly about a Meets minimum requirements, b In process, c Behind schedule, d Health waiver, e Religious waiver, f Personal conviction waiver, g No record, MMR, a Meets minimum requirements, b In process, c Behind schedule, d Health waiver, e Religious waiver, f Personal conviction waiver, and g No record - type in each of these fields.

Part no. 3 in filling out Td

4. Your next subsection will require your input in the following areas: c Behind schedule, d Health waiver, e Religious waiver, f Personal conviction waiver, g No record Tdap th grade through, and dose required. It is important to provide all of the required information to go further.

Completing segment 4 in Td

5. This document should be finished by filling out this area. Below there is a comprehensive listing of form fields that require appropriate details in order for your document submission to be accomplished: b In process, c Behind schedule, d Health waiver, e Religious waiver, f Personal conviction waiver, Page of, g No record Put zeros if there, Including K or early childhood K, Put zeros if there are no Grade, Section C list the number of, Students who are in process, Kindergarten Students, and All students.

Filling in part 5 in Td

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