Free 48973.pdf - Indiana

SUMMARY REPORT ON THE IMMUNIZATION STATUS OF KINDERGARTEN STUDENTS ENROLLED IN SCHOOL
State Form 48973 (R10 / 8-08) IC 20-34-4-6

SCHOOL YEAR ________
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CODES County Number

Name of School Corporation

Name of School

Address of School

Corporation Number County School Number

K

City

Zip Code

School Telephone Number

Each school that has their own school number listed in the Indiana School Directory, published by the Department of Education, must submit a separate report. The answer for each box below must be a number (No Check Marks, etc.) ENTER IN BOX THE NUMBER OF KINDERGARTEN STUDENTS IN YOUR SCHOOL: A.

NUMBER OF STUDENTS FROM BOX "A" ABOVE HAVING COMPLETED IMMUNIZATIONS:
See the work sheet for the minimum complete immunizations. Students listed in this category need no further follow-up.

B.

EXEMPTIONS: NUMBER OF STUDENTS FROM BOX "A" ABOVE WHO HAVE A MEDICAL CONTRAINDICATION ON FILE:
A physician's signed statement, verified annually and kept in your school immunization records, is required.

C.

NUMBER OF STUDENTS FROM BOX "A" ABOVE WHO HAVE A RELIGIOUS OBJECTION ON FILE:
A statement, signed and verified annually by a parent/guardian stating the objection, must be on file in your school immunization records.

D.

NUMBER OF STUDENTS FROM BOX "A" ABOVE NOT COMPLETE AND HAVING NO EXEMPTION ON FILE: If there is a number (other than 0) in Box "E" then Boxes "F" thru "N" must be completed.
Total Students that fall into these categories (Not Doses):

E.

R E A (F) S O N S

Record not on file

Need DTaP/DT/ Td

Need Polio

Need Hepatitis B

Need 1st Measles

Need 2nd Measles

Need Rubella

Need Mumps

Need Varicella

(G)

(H)

(I)

(J)

(K)

(L)

(M)

(N)

Return this form to: Indiana State Department of Health Immunization Program, 6A 2 North Meridian Street Indianapolis, IN 46204-3003

Signatures: _______________________________________ Superintendent ________________________________________ Prepared By