Nj Annual Immunization Report Form PDF Details

The New Jersey Annual Immunization Status Report, facilitated by the New Jersey Department of Health, plays a pivotal role in ensuring the health and safety of students and children in educational and childcare facilities across the state. It mandates the rigorous documentation and reporting of immunization records for attendees ranging from pre-kindergarten through to grade 6, including transfer students from out-of-state or out-of-country locations. The form, detailed in its requirements, seeks vital information such as school identification, total enrollment details, and the immunization status of all required pupils—categorizing them into those meeting all applicable immunization requirements, those with provisional admittance, and those exempt due to medical or religious reasons. Additionally, it introduces the Influenza Vaccine Implementation Survey (IVIS) aimed at assessing the effectiveness of flu vaccination programs for preschool-aged children, highlighting the state’s commitment to preventing influenza outbreaks within these settings. Carefully designed to collect comprehensive data, this report aids in ensuring compliance with New Jersey’s stringent immunization laws, ultimately safeguarding the well-being of the community’s youngest members.

QuestionAnswer
Form NameNj Annual Immunization Report Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameswww njannualimmunizationreport, imm7 report, imm7, imm7 report nj

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New jersey Department of Health

N J H om e | Se r v ice s A t o Z | D e pa r t m e n t s/ Age n cie s | FAQs

Se a r ch

This Sit e

D OH H om e

An n u a l I m m u n iz a t ion St a t u s Re por t

* Required Fields

*Sch ool I D :

*Cou n t y :

School Dist rict :

* Nam e of School/ Child Care Facilit y:

I f Facilit y Recent ly Changed Nam e, List Previous Nam e:

M a ilin g Addr e ss:

*St reet :

*Cit y:

Sch ool Addr e ss ( if dif f e r e n t f r om a bov e )

St reet :

Cit y:

-

 

Mu n cipalit y

Select a County

Code:

 

* Zip Code:

Zip Code:

( not required)

*Nam e of Person Com plet ing t he Form :

School Em ail Address:

Nam e of Principal/ Person in Charge:

* Tot al School/ Child Care Cent er Enrollm ent :

*Elem ent ary/ Secondary School/ Child Care Facilit y:

* Telephone:

Tit le:

Public Non - Public

The school is responsible for assuring t hat all pupils are in com pliance w it h t he New Jersey

I m m unizat ion requirem ent s. I n t he boxes below , ent er t he st at us of all pupils in your ent ry level grade, grade 6, and t ransfer st udent s ( any grade) .

Child care facilit ies m ust ent er t he im m unizat ion st at us of all enrolled children w ho are over 2 m ont hs of age on t he pre - k line

I f your school has pre - kindergart en classes , ent er t hose children on t he pre - k line.

I f your school has a kindergart en grade , ent er t hose children on t he kindergart en line.

Do not include dat a in t he grade 1 boxes unless t he st udent is beginning school for t he very first t im e in grade 1 .

All pupils ent ering grade 6 record on t he grade 6 line.

Ungraded special educat ion pupils should be included w it h t he appropriat e age cohort class.

N ot

* N u m be r of

Pu pils M e e t in g All

+ Pu pils w it h Pu pils w it h Pu pils w it h Pu pils w it h

Gr a de Le v e lPu pils

Applica ble En r olle d

Im m u n iz a t ion Re qu ir e m e n t s

Pr ov ision a l

M e dica l

Re ligiou s

St a t u s

Adm it t a n ce

Ex e m pt ion s

Ex e m pt ion s

U n k n ow n

Pr e - k :

Kin der gar t en :

Grade 1:

Grade 6:

** Transfer St udent s

( Out of

St at e/ Count ry only) :

+ Provisional Adm it t ance - t hose pupils w ho have begun or are in t he process of com plet ing all t he required im m unizat ions.

* * Transfer St udent s - all st udent s new ly t ransferred int o grades K- 12 from any out - of - st at e/ out - of count ry school since subm ission of last year's st at us report .

* Opt ional

I f you do n ot have any st udent s under 60 m ont hs of age, t hank you for com plet ing your Annual I m m unizat ion St at us Report . Please click on subm it and print out your subm ission .

I f you have st udent s under 60 m ont hs of age, please consider assist ing us in assessing t he efficacy of t he influenza vaccine requirem ent . To part icipat e in I nfluenza Vaccine I m plem ent at ion Survey ( I VI S) , please click 'Yes' below . To not part icipat e, please click on 'No' .

Are you w illing t o com plet e t he I VI S?

Yes

No

I n f lu e n z a V a ccin e I m ple m e n t a t ion Su r v e y ( I V I S)

As per N. J. A. C. 8: 57 - 4 . 19, children six m ont hs t hrough 59 m ont hs of age at t ending any licensed child care cent er, or preschool facilit y shall annually receive at least one dose of influenza vaccine bet w een Sept em ber 1 and Decem ber 31 of each year .

Alt hough t he survey is volunt ary, w e need t o evaluat e t he com pliance w it h and t he effect iveness of t he influenza vaccinat ion program s for preschool aged children . We appreciat e your cooperat ion in filling out t his survey .

Tot a l # of St u de n t s

 

 

 

 

 

 

 

 

 

be t w e e n a ge s 6 - 5 9

Tot a l # of St u de n t s w h o r e ce iv e d

Tot a l # of Re ligiou s

Tot a l # of M e dica l

m os. su bj e ct t o t h e

in f lu e n z a v a ccin e by D e ce m be r

Ex e m pt ion s f or in f lu e n z a

Ex e m pt ion s gr a n t e d f or

 

in f lu e n z a

 

3 1 st

 

v a ccin e

in f lu e n z a v a ccin e

r e qu ir e m e n t

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D e pa r t m e n t of H e a lt h

P.O. Box 360, Trent on, NJ 08625 - 0360

Our Locat ions

depart m ent : nj doh hom e | index

by t opic | program s/ services

st at ew ide: nj hom e | services A t o

Z | Depart m ent s/ Agencies | FAQs

Copyright © St at e of New Jersey, 1996 - 2014

Last Modified: Monday, 29 - Dec- 14 11: 47: 23

http://highpoint.state.nj.us/health/cd/imm7/annualstatusrpt_form_current.shtml[12/29/2014 11:48:27 AM]

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