Thank you for participating in the 2022-2023 Annual School Immunization Survey! This survey is designed to assess vaccination coverage among public and private schools in Maryland. The data collected will be used to assure compliance with Maryland school immunization regulations (MDH COMAR 10.06.04.03).

All public and private schools in Maryland are required by COMAR to complete the survey.

Please answer all questions completely. Blanks should be noted as zero ("0") when appropriate.

If you would like a printed copy of the survey for your records, you must print the survey prior to hitting the "Submit" button. You can do this by right clicking your mouse and selecting "Print"

This is due Friday, November 18, 2022

Please feel free to call the Center for Immunization at 410-767-5716 if you need assistance or have questions.

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* 1. Contact Information:

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* 2. Date the report completed:

Date

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* 3. School Information:

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* 4. Please select the county/jurisdiction in which your school is located (distinguish between Baltimore City and Baltimore County):

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* 5. What grade levels are included in your school?  (Check all that apply)

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* 6. Type of school? (Check one)

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* 7. What is the TOTAL number of the students enrolled in your school in each of the following grades? This count should be based on ALL students in your school.  Question 1 on the paper form.

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* 8. What is the TOTAL number of students NEWLY ENROLLED in your school in each of the following grades? Do NOT include students that were in the building last year.  Question 2 on the paper form.

The next two questions in this survey should only include ALL kindergarten students and NEWLY ENROLLED STUDENTS IN YOUR SCHOOL BUILDING in grades 1-12 (those students that you identified in question 7 for your Kindergarten and question 8 for your grades 1-12).   
 
Newly enrolled students refer to students in that grade who were NOT enrolled in your school building the previous year.  If students are enrolling from a feeder school (i.e. Elementary to Middle; Middle to High), they would be considered NEWLY ENROLLED to your school and counted as NEW.    

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* 9. What is the number of students with medical exemptions in each of the following grades? Question 3 on the paper form.

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* 10. What is the number of students with religious exemptions in each of the following grades? Question 4 on the paper form.

For the rest of the questions, DO NOT include students with medical or religious exemptions. 

Calculation Hint:  Questions 12 and 13 added together should equal question 11 for each grade.  If they do not, please check your numbers.  

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* 11. What is the number of students surveyed?  To determine the number to use for this question, you should take ALL kindergarten students and ONLY NEWLY ENROLLED IN YOUR SCHOOL BUILDING grade 1-12 students and subtract the number of medical and religious exemptions for each grade.  
Question 5 on the paper form.

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* 12. What is the number of students WITH immunization records in each of the following grades? DO NOT include students with medical or religious exemptions. Question 6 on the paper form.

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* 13. What is the number of students WITHOUT ANY immunization record in each of the following grades? DO NOT include students with medical or religious exemptions. Question 7 on the paper form.

REMEMBER: The rest of the questions in this survey should be based on the students identified in question 11 in the online survey/question 5 in the paper survey (ALL kindergarten students and ONLY NEWLY ENROLLED STUDENTS IN YOUR SCHOOL BUILDING in grades 1-12 minus medical/religious exemptions).

Students with medical or religious exemptions should NOT be included in these questions.

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* 14. What is the number of students who need 1 or more doses of DTaP/DTP/DT/Tdap/Td vaccine in each of the following grades? Question 8 on the paper form.

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* 15. What is the number of students records who need 1 or more doses of Polio vaccine in each of the following grades? Question 9 on the paper form.

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* 16. What is the number of students who need 1 or more doses of Measles, Mumps, and Rubella (MMR) vaccine in the following grades? Question 10 on the paper form.

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* 17. What is the number of students who need 1 or more doses of Hepatitis B vaccine in the following grades? Question 11 on the paper form.

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* 18. What is the number of students (with no history of chickenpox disease), who need 1 or more doses of Varicella vaccine in the following grades? Question 12 on the paper form.

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* 19. What is the number of 7th grade students, who need 1 dose of Meningococcal vaccine? NOTE: This count should be based on ONLY newly enrolled students in grades 7 (not including students with exemptions).  Question 13 on the paper form.

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