Requirements Met, But Missing Doses
Permanent Medical Exemption
Other: IEP Services
F1
Conditional- Missing Doses Not Currently Due B
Temporary Medical Exemption
D
Overdue- Needs Doses Now G
TOTAL
Total number of Pre-Kindergarten Students:
1
2
3
School
Information
Contact
Information
Summary
Report
Requirements Met
Includes homeless or foster care students in process of
locating records
pre-2016
Personal Belief Exemption E
All Required Vaccine Doses A
UNCONDITIONAL ADMISSION:
CONDITIONAL ADMISSION, NEED FOLLOWUP:
Missing Doses By Vaccine
Students are missing doses.
Total number of students missing each vaccine:
Polio Hep B
DTaP Varicella
MMR
Hib
REQUIREMENTS NOT MET, MISSING DOSES
SCHOOL INFORMATION
School Name:
CDE School Code:
Type:
County:
DESIGNATED SCHOOL CONTACT
Name:
Email:
Phone Number:
STAFF MEMBER COMPLETING THIS FORM
Name:
Email:
Phone Number:
Administer/Principal:
School Email:
Physical Address:
Account for each student in one of the categories below.
Includes MD/DO verification of varicella disease
C
private public headstart
Pre-Kindergarten
Immunization Assessment
Note: This form is for accounting purposes only
and should be kept for your reference.
Please log-in to shotsforschool.org/reporting
to complete the immunization assessment
summary online.
