Nj Annual Immunization Report Form PDF Details

With returning students and staff to schools, now is the time for families and healthcare providers to review immunizations. The State of New Jersey recently released a report form required by those attending childcare programs and school that assess current immunization status. If a child isn't up-to-date on their vaccinations or are exempt from receiving them, this must be reported annually in order for them to participate in these programs. In this blog post, we'll discuss the Nj Annual Immunization Report Form as well as who needs one and how it should be completed.

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

Form Preview Example

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]

How to Edit Nj Annual Immunization Report Form Online for Free

You could work with canine da2 immnization effortlessly with the help of our PDFinity® PDF editor. FormsPal team is devoted to providing you with the ideal experience with our tool by regularly releasing new capabilities and enhancements. Our tool is now much more helpful as the result of the latest updates! Now, filling out PDF documents is a lot easier and faster than ever before. To begin your journey, go through these simple steps:

Step 1: Just hit the "Get Form Button" in the top section of this webpage to open our pdf form editing tool. This way, you will find everything that is necessary to fill out your file.

Step 2: As soon as you launch the editor, you will see the document prepared to be filled in. Other than filling in different blanks, you can also perform some other things with the form, including putting on your own words, changing the initial text, adding graphics, placing your signature to the form, and a lot more.

With regards to the fields of this particular document, here's what you should consider:

1. While filling out the canine da2 immnization, ensure to incorporate all of the important blanks within the corresponding area. It will help hasten the process, allowing your information to be processed fast and accurately.

Learn how to fill in nj imm7 annual status report part 1

2. Your next step is to fill in all of the following blanks: D e pa r t m e n t of H e a lt h, P O Box Trent on NJ, Our Locat ions, depart m ent nj doh hom e index, and Last Modified Monday Dec.

Stage number 2 for filling out nj imm7 annual status report

People often make mistakes when filling out Our Locat ions in this part. Be sure you reread whatever you type in here.

Step 3: Just after taking one more look at the form fields you have filled out, click "Done" and you are good to go! Sign up with FormsPal today and immediately obtain canine da2 immnization, all set for download. Every edit you make is conveniently preserved , enabling you to change the file later on if necessary. We don't share or sell the details you enter whenever filling out documents at FormsPal.

Nj Annual Immunization Report Form isn’t the one you’re looking for?

Related Documents