Thank you for participating in the 2016-2017 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 (DHMH 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"

Please feel free to call the Center for Immunization at 410-767-6679 if you need assistance or have questions.

* 1. Contact Information:

* 2. Date the report was completed:

Date
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* 3. School Information:

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

* 6. Type of school? (Check one)

* 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, regardless of whether they are newly enrolled or not.  Question 1 on the paper form.

* 8. What is the number of students with medical exemptions in each of the following grades? Question 2 on the paper form.

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

NOTE: The rest of the questions in this survey should include ALL kindergarten students and ONLY NEWLY ENROLLED STUDENTS IN YOUR SCHOOL BUILDING in grades 1-12.


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

* 10. 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 4 on the paper form.

* 11. What is the number of students WITHOUT immunization records in each of the following grades? DO NOT include students with medical or religious exemptions. Question 5 on the paper form.

* 12. What is the TOTAL number of student records being surveyed? DO NOT include students with medical or religious exemptions.  This number should equal the sum of questions 10 and 11 of this online survey. Question 6 on the paper form.

REMEMBER: The rest of the questions in this survey should include ALL kindergarten students and ONLY NEWLY ENROLLED STUDENTS IN YOUR SCHOOL BUILDING in grades 1-12.

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

* 13. 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 7 on the paper form.

* 14. What is the number of students records who need 1 or more doses of Polio vaccine in each of the following grades? Question 8 on the paper form.

* 15. What is the number of students who need 1 or more doses of Measles, Mumps, and Rubella (MMR) vaccine in the following grades? Question 9 on the paper form.

* 16. What is the number of students who need 1 or more doses of Hepatitis B vaccine in the following grades? Question 10 on the paper form.

* 17. 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 11 on the paper form.

* 18. What is the number of 7th, 8th, and 9th grade students, who need 1 dose of Meningococcal vaccine? NOTE: This count should be based on ONLY newly enrolled students in grades 7-9 (not including students with exemptions).  Question 12 on the paper form.

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