Free 48971.pdf - Indiana

SUMMARY REPORT ON THE IMMUNIZATION STATUS OF SIXTH GRADE STUDENTS ENROLLED IN SCHOOL
State Form 48971 (R11/8-08) IC 20-34-4-6

SCHOOL YEAR ________
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CODES

Name of School Corporation

Name of School

County Number

Address of School

Corporation Number County School Number

6

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 sixth grade students in your school:

A.

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.

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.

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 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

(F)

(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