IMM-14, Immunization Audit Report Worksheet
|New Jersey Department of Health |IMMUNIZATION AUDIT REPORT WORKSHEET |
|Vaccine Preventable Disease Program | |
|* Required Fields | |
|*Name of School/Childcare Center |*ASR School ID |*Mailing Address |*City |
| | | | |
|*School Contact Person |*Telephone Number |*Email Address |
| | | |
|*Grades in School |*Total School Enrollment |*Total Enrolled/Surveyed |
|From: ________ To: ________ | |CC/Pre: ________ K/1: ________ 6: ________ Transfer (Any Grade): ________ |
|*Audit Date |*Name of Auditor |*Name of Auditing Agency |*Telephone Number |*Email Address |
| | | | | |
|pupils EXEMPTED |Missing VACCINE Antigens |Pupil |Comments |
|OR Not Compliant |Indicate missing vaccine; as appropriate, list (M) for Medical Exemption, (R) for Religious |Excluded | |
| |Exemption, and (P) for Provisional. | | |
|Name |Grade |No Record|All |DTaP/ |Polio |Measles |HIB |Hep B |Varicella|PCV13 |Flu |MCV4 | | |
| | | |Vaccines |DT/Td/ | |Mumps | | | | | | | | |
| | | | |Tdap | |Rubella | | | | | | | | |
| | | | | | |(MMR) | | | | | | | | |
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IMM-14
OCT 15 Page of Pages.
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