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) | | | | | | | | |

|Date of Birth | | | | | | | | | | | | | | |

|1.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|2.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|3.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|4.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|5.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|6.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|7.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|8.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|9.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

|10.       |      |      |      |      |      |      |      |      |      |      |      |      |      |      |

|       | | | | | | | | | | | | | | |

IMM-14

OCT 15 Page       of       Pages.

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