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The NJ Annual Immunization Report Form is a crucial document designed by the New Jersey Department of Health. It serves to ensure compliance with the state's immunization requirements. Schools and child care facilities are required to submit this form annually, reporting the immunization status of their enrollees across various age and grade levels.

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Content Overview

The New Jersey Annual Immunization Status Report Form is a comprehensive document introduced by the New Jersey Department of Health to ensure that all schools and childcare facilities maintain up-to-date records of student vaccinations, as per state immunization requirements. This crucial form gathers detailed information about the immunization status of students across various educational levels—from childcare facilities to elementary and secondary schools. It obligates reporting on the total enrollment and vaccination compliance, including provisional admittance and exemptions based on medical or religious grounds. Additionally, it covers special considerations for transfer students and those in ungraded special education. The form also extends to evaluating the influenza vaccine's effectiveness among preschool-aged children through a voluntary survey. By submitting this report, schools affirm their commitment to public health and compliance with New Jersey's stringent immunization mandates, playing a pivotal role in safeguarding community well-being against preventable diseases.

Document Sample

New jersey Department of Health

N J H om e | Se r v ice s A t o Z | D e pa r t m e n t s/ Age n cie s | FAQs

Se a r ch

This Sit e

D OH H om e

An n u a l I m m u n iz a t ion St a t u s Re por t

* Required Fields

*Sch ool I D :

*Cou n t y :

School Dist rict :

* Nam e of School/ Child Care Facilit y:

I f Facilit y Recent ly Changed Nam e, List Previous Nam e:

M a ilin g Addr e ss:

*St reet :

*Cit y:

Sch ool Addr e ss ( if dif f e r e n t f r om a bov e )

St reet :

Cit y:

-

 

Mu n cipalit y

Select a County

Code:

 

* Zip Code:

Zip Code:

( not required)

*Nam e of Person Com plet ing t he Form :

School Em ail Address:

Nam e of Principal/ Person in Charge:

* Tot al School/ Child Care Cent er Enrollm ent :

*Elem ent ary/ Secondary School/ Child Care Facilit y:

* Telephone:

Tit le:

Public Non - Public

The school is responsible for assuring t hat all pupils are in com pliance w it h t he New Jersey

I m m unizat ion requirem ent s. I n t he boxes below , ent er t he st at us of all pupils in your ent ry level grade, grade 6, and t ransfer st udent s ( any grade) .

Child care facilit ies m ust ent er t he im m unizat ion st at us of all enrolled children w ho are over 2 m ont hs of age on t he pre - k line

I f your school has pre - kindergart en classes , ent er t hose children on t he pre - k line.

I f your school has a kindergart en grade , ent er t hose children on t he kindergart en line.

Do not include dat a in t he grade 1 boxes unless t he st udent is beginning school for t he very first t im e in grade 1 .

All pupils ent ering grade 6 record on t he grade 6 line.

Ungraded special educat ion pupils should be included w it h t he appropriat e age cohort class.

N ot

* N u m be r of

Pu pils M e e t in g All

+ Pu pils w it h Pu pils w it h Pu pils w it h Pu pils w it h

Gr a de Le v e lPu pils

Applica ble En r olle d

Im m u n iz a t ion Re qu ir e m e n t s

Pr ov ision a l

M e dica l

Re ligiou s

St a t u s

Adm it t a n ce

Ex e m pt ion s

Ex e m pt ion s

U n k n ow n

Pr e - k :

Kin der gar t en :

Grade 1:

Grade 6:

** Transfer St udent s

( Out of

St at e/ Count ry only) :

+ Provisional Adm it t ance - t hose pupils w ho have begun or are in t he process of com plet ing all t he required im m unizat ions.

* * Transfer St udent s - all st udent s new ly t ransferred int o grades K- 12 from any out - of - st at e/ out - of count ry school since subm ission of last year's st at us report .

* Opt ional

I f you do n ot have any st udent s under 60 m ont hs of age, t hank you for com plet ing your Annual I m m unizat ion St at us Report . Please click on subm it and print out your subm ission .

I f you have st udent s under 60 m ont hs of age, please consider assist ing us in assessing t he efficacy of t he influenza vaccine requirem ent . To part icipat e in I nfluenza Vaccine I m plem ent at ion Survey ( I VI S) , please click 'Yes' below . To not part icipat e, please click on 'No' .

Are you w illing t o com plet e t he I VI S?

Yes

No

I n f lu e n z a V a ccin e I m ple m e n t a t ion Su r v e y ( I V I S)

As per N. J. A. C. 8: 57 - 4 . 19, children six m ont hs t hrough 59 m ont hs of age at t ending any licensed child care cent er, or preschool facilit y shall annually receive at least one dose of influenza vaccine bet w een Sept em ber 1 and Decem ber 31 of each year .

Alt hough t he survey is volunt ary, w e need t o evaluat e t he com pliance w it h and t he effect iveness of t he influenza vaccinat ion program s for preschool aged children . We appreciat e your cooperat ion in filling out t his survey .

Tot a l # of St u de n t s

 

 

 

 

 

 

 

 

 

be t w e e n a ge s 6 - 5 9

Tot a l # of St u de n t s w h o r e ce iv e d

Tot a l # of Re ligiou s

Tot a l # of M e dica l

m os. su bj e ct t o t h e

in f lu e n z a v a ccin e by D e ce m be r

Ex e m pt ion s f or in f lu e n z a

Ex e m pt ion s gr a n t e d f or

 

in f lu e n z a

 

3 1 st

 

v a ccin e

in f lu e n z a v a ccin e

r e qu ir e m e n t

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D e pa r t m e n t of H e a lt h

P.O. Box 360, Trent on, NJ 08625 - 0360

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Copyright © St at e of New Jersey, 1996 - 2014

Last Modified: Monday, 29 - Dec- 14 11: 47: 23

http://highpoint.state.nj.us/health/cd/imm7/annualstatusrpt_form_current.shtml[12/29/2014 11:48:27 AM]

Form Attributes

Fact Detail
Purpose The form is used by schools and child care facilities in New Jersey to report the immunization status of their pupils.
Requirement Reporting on this form is required to ensure compliance with New Jersey Immunization Requirements.
Specific Groups The form seeks detailed immunization information about entry-level grade students, grade 6 students, transfer students, and, in certain cases, preschool-aged children.
Provisional Admission Clause It allows for the provisional admission of pupils who have begun but not completed all required immunizations.
Governing Law As per N.J.A.C. 8:57-4.19, children six months through 59 months of age attending any licensed child care center, or preschool facility must receive at least one dose of the influenza vaccine between September 1 and December 31 of each year.

Nj Annual Immunization Report: Usage Guide

The New Jersey Annual Immunization Status Report is a necessity for schools and child care facilities to ensure all enrolled pupils comply with the state's immunization requirements. It requires accurate reporting of pupils' immunization status across different grades and categories. This detailed process involves collecting and reporting data on those meeting requirements, provisional admissions, and those with medical or religious exemptions. The subsequent steps are designed to assist you in accurately completing the form.

  1. Begin by entering the School ID and selecting the County from the drop-down menu.
  2. Provide the Name of School/Child Care Facility. If the facility has recently changed its name, list the previous name in the specified field.
  3. Fill in the Mailing Address section, including the Street and City. Include the zip code where indicated.
  4. If the school address differs from the mailing address, enter the different street and city details under the School Address section (though zip code is not required).
  5. Enter the Name of the Person Completing the Form, including their title, and the school email address.
  6. Provide the Name of Principal/Person in Charge and the Total School/Child Care Center Enrollment number.
  7. Select whether the facility is a Public or Non-Public entity.
  8. For each grade level specified (Pre-K, Kindergarten, Grade 1, Grade 6), enter the number of pupils according to their immunization status: Meeting All Applicable Immunization Requirements, Provisional Admission, Medical Exemptions, Religious Exemptions, and Unknown.
  9. Include numbers for Transfer Students (Out of State/Country only), adhering to the same categorization as above.
  10. If your school does not serve students under 60 months of age, submit the form after verifying all entered information is correct. Click on 'Submit' and print out your submission for recordkeeping.
  11. If your school includes students under 60 months of age and wishes to participate in the Influenza Vaccine Implementation Survey (IVIS), select 'Yes' to proceed with the additional survey.

By conscientiously filling out the New Jersey Annual Immunization Status Report, your facility contributes vital information that aids in maintaining public health standards for children. This process ensures the safety and well-being of all pupils by upholding state immunization requirements.

Listed Questions and Answers

What is the NJ Annual Immunization Report?

The NJ Annual Immunization Report is a required form that schools and child care facilities in New Jersey must submit to the Department of Health. It details the immunization status of enrolled students, ensuring compliance with the state's immunization requirements.

Who needs to complete the NJ Annual Immunization Report?

Any school or child care facility within New Jersey, regardless of being public or non-public, must complete this report. It covers all enrolled pupils in entry-level grades, grade 6, transfer students from out-of-state or out of the country, and, for child care facilities, all children over 2 months of age in pre-K.

What information is required on the form?

The form requires detailed information about the facility, including:

  • School ID and County
  • Name and address of the School/Child Care Facility
  • Name and email of the person completing the form
  • Total enrollment numbers
  • Immunization status of the pupils in specified grades or age groups

How are provisional admittances handled?

Provisional admittance is granted to pupils who have begun or are in the process of completing all required immunizations. These pupils should be accounted for separately in the report, indicating their progress towards meeting New Jersey's immunization mandates.

Are there exemptions to the immunization requirements?

Yes, exemptions include medical or religious grounds. the report includes sections where schools can denote the number of pupils with such exemptions. It's crucial that these are documented accurately for compliance and record-keeping purposes.

What about transfer students?

Transfer students, those who are newly transferred into grades K-12 from any out-of-state or out-of-country school since the submission of the last year's status report, have a separate designation on the form. This helps track the immunization compliance of students who may not have been previously accounted for in the New Jersey system.

Is participation in the Influenza Vaccine Implementation Survey (IVIS) mandatory?

No, participation in the IVIS is voluntary. However, this survey assists in assessing the effectiveness of the influenza vaccination programs for preschool-aged children. Schools with students under 60 months of age are encouraged to participate.

How can facilities submit the NJ Annual Immunization Report?

After filling out the necessary information, facilities can submit the form electronically through the provided link on the New Jersey Department of Health's website. It’s recommended to print out a submission confirmation for record-keeping.

Where can schools and facilities find help if they have questions?

For assistance, schools and facilities can contact the New Jersey Department of Health directly. The department offers guidance and support for completing and submitting the Annual Immunization Status Report, ensuring all requirements are met efficiently.

Common mistakes

When filling out the New Jersey Annual Immunization Status Report form, several common mistakes can impact the submission's accuracy and compliance. Awareness of these errors is crucial for schools and child care facilities to ensure they accurately report their immunization status. Here are six common mistakes:

  1. Not double-checking the School ID and County information: It's crucial to accurately fill in the School ID and County fields. Errors here can lead to the report being misfiled or not recognized, affecting the facility's compliance status.
  2. Omitting details about the facility’s recent name change: If the school or child care facility has recently changed its name, failing to list its previous name can cause confusion or delays in processing the report.
  3. Inaccurate total enrollment numbers: Reporting incorrect total school or child care center enrollment figures can significantly impact the assessment of compliance and the effectiveness of the immunization program.
  4. Confusion between school and mailing addresses: It's essential to distinguish clearly between the facility's physical location and its mailing address. Misreporting these can lead to important communications being missed.
  5. Neglecting to report the immunization status for specific groups: The form requires the entry of immunization status for entry-level grades, grade 6, and transfer students. Overlooking or inaccurately reporting this information compromises the report's integrity.
  6. Incorrectly handling exemptions and provisional admissions: Schools must accurately report the number of students with medical or religious exemptions, as well as those with provisional admittance. Mistakes in these fields can affect the perceived immunization coverage and compliance.

To ensure the accuracy and completeness of the Annual Immunization Status Report, it is beneficial for individuals responsible for its preparation to carefully review all entries and adhere strictly to the New Jersey Department of Health's guidelines.

Documents used along the form

Filling out the New Jersey Annual Immunization Status Report form is a crucial step for schools and child care facilities to comply with state health regulations. However, this form is usually not the only document required. Below is a list of other forms and documents often used alongside it to ensure comprehensive health and safety compliance within educational and child care environments.

  • Vaccine Administration Record (VAR): This document provides a detailed account of each immunization a child receives, including the vaccine name, date of administration, dosage, and administrator details.
  • Medical Exemption Form: For children who cannot be vaccinated due to medical reasons, this form, completed by a healthcare provider, outlines the medical basis for exemption from immunization requirements.
  • Religious Exemption Statement: A written statement signed by the parent or guardian declaring that immunization conflicts with their bona fide religious beliefs and practices.
  • Parental Consent for Immunization: This form is used to obtain consent from a parent or guardian for the administration of vaccines to a minor.
  • Child Health Record: A comprehensive record that includes a child's immunization history, as well as other pertinent health information such as allergies, medical conditions, and emergency contacts.
  • Influenza Vaccine Consent Form: Specific consent form used for the administration of the flu vaccine, in alignment with New Jersey's annual influenza vaccine requirement for children in licensed child care and preschool facilities.
  • Out-of-State Transfer Immunization Documentation: For students transferring from out of state, this documentation provides proof of immunizations received prior to enrollment in a New Jersey school or child care facility.
  • Immunization Audit Toolkit: A resource for schools and child care facilities to ensure compliance with immunization reporting requirements, including checklists and logs for tracking immunization status.
  • Notice of Incomplete Immunization Record: A notice sent to parents or guardians when a child's immunization record is incomplete, detailing missing vaccines and the timeframe for compliance.
  • Annual Influenza Vaccine Implementation Survey (IVIS) Consent: Although the IVIS is voluntary, participation consent is sought from schools and child care facilities to assess the effectiveness of influenza vaccination programs for preschool-aged children.

Together with the New Jersey Annual Immunization Status Report, these documents form a robust framework for ensuring the well-being and safety of children in educational and care settings. By meticulously completing and updating these records, schools and child care facilities play a vital role in upholding public health standards and safeguarding the community against vaccine-preventable diseases.

Similar forms

The Vaccine Administration Record (VAR) is one document that shares similarities with the NJ Annual Immunization Report form. Both documents are used to track and report vaccinations. While the NJ form focuses on the immunization status of students within educational institutions, the VAR typically documents individual vaccine administration events, tracking the vaccine type, dose, and date given to a person. Both forms play critical roles in maintaining public health records and ensuring compliance with vaccination requirements.

Another related document is the Medical Exemption Form for Vaccinations. This form, like a section of the NJ Annual Immunization Report, is used when individuals are exempt from getting certain vaccines due to medical reasons. Both documents require detailed information to confirm the validity of the exemption and to maintain accurate public health records, ensuring that all exemptions are properly accounted for within compliance efforts.

The Religious Exemption Form for Immunizations is akin to parts of the NJ Annual Immunization Report that record religious exemptions. This form allows individuals to claim an exemption from vaccinations based on religious beliefs. Both the NJ report and the religious exemption form underscore the importance of documenting exemptions to vaccination mandates, ensuring that schools and child care facilities adhere to legal requirements while respecting individual beliefs.

The School Vaccination Requirements Checklist, much like the NJ report, serves schools and child care facilities. It outlines the specific vaccines children must receive at certain age levels or grades. This checklist is a tool for educational institutions to ensure that they are in compliance with state immunization laws, paralleling the NJ form's function of collecting and reporting the immunization status of students to health authorities.

The Child Care Immunization Record is another document with a similar purpose to the NJ Annual Immunization Report. Focused on younger children in pre-kindergarten and child care settings, this form tracks the immunization status of enrolled children, ensuring that they meet state-mandated vaccine requirements. Both documents are necessary for evaluating compliance with vaccine laws in environments where young children are cared for outside their homes.

The Immunization Survey Form is utilized to gather data on vaccination rates within a particular community or institution, similar to the optional influenza vaccine implementation survey mentioned in the NJ form. Both surveys aim to assess the coverage and effectiveness of vaccination programs, helping public health officials to identify areas with low immunization rates and to develop strategies to increase vaccine uptake.

The Student Health Record, which encompasses a student's comprehensive health history, including immunizations, is another document with similarities to the NJ Annual Immunization Report. While the health record provides a detailed view of a student's health over time, including allergies, medications, and physical exam results, the section regarding immunizations aligns closely with the purpose of the NJ report, ensuring that the student meets school entry requirements.

The Influenza Vaccine Documentation Form, specifically related to the influenza vaccine data collection in the NJ report, is used to track flu vaccine administration in various settings. This form, like the NJ report's optional influenza survey, helps health departments and educational institutions measure compliance with flu vaccine recommendations and mandates, particularly for children in daycare and preschool settings.

Lastly, the Vaccine Inventory Log shares a logistical similarity with the NJ Annual Immunization Report. While the inventory log is primarily used by healthcare providers to manage and record vaccine supplies, it indirectly supports the accuracy of immunization reporting by ensuring that adequate vaccine stock is available for administration. Proper inventory management contributes to the overall effectiveness of public health vaccination initiatives, aligning with the goals of the NJ immunization report.

Dos and Don'ts

When completing the New Jersey Annual Immunization Status Report form, there are essential steps to follow to ensure accuracy and compliance with state requirements. Please consider the following dos and don'ts:

Do:
  • Review all required fields carefully to ensure no necessary information is missed. Each field marked with an asterisk (*) is mandatory.
  • Double-check the immunization statuses of all students, including those in entry-level grades, grade 6, and transfer students, to accurately reflect their current immunization records.
  • Include information on provisional admissions, medical exemptions, and religious exemptions accurately, as these details are critical for understanding the overall immunization status of your student population.
  • Participate in the Influenza Vaccine Implementation Survey (IVIS) if your institution includes students under 60 months of age, as this information is valuable in assessing the efficacy of influenza vaccination programs.
Don't:
  • Omit the previous name of the facility if it has recently changed. This information is crucial for maintaining continuity in records and ensuring accurate tracking of immunization data.
  • Forget to include the total enrollment number at your school or child care center. This overall count is necessary for the Department of Health to assess immunization coverage and compliance rates.
  • Overlook the importance of accuracy in reporting the number of pupils meeting all applicable immunization requirements versus those with exemptions or unknown status. Precise data is key to statewide public health efforts.
  • Skip the option to submit additional data regarding students under 60 months of age, if applicable. Even though this section is optional, your participation helps in evaluating the success of mandatory influenza vaccination policies.

Misconceptions

There are several misconceptions about the New Jersey Annual Immunization Status Report form that need clarification. These misunderstandings can lead to confusion about the reporting requirements and the nature of the information that needs to be submitted.

  • Only public schools need to submit the report. This is incorrect. Both public and non-public schools are required to submit the Annual Immunization Status Report. The form gathers immunization data from all types of educational institutions, including child care facilities, to ensure compliance with New Jersey's immunization requirements.
  • It's only about flu vaccines. While there is a portion of the form dedicated to the influenza vaccine, particularly for preschool-aged children, the report covers a broad range of immunizations. The form is designed to collect data on the full spectrum of required vaccinations, not just flu shots.
  • The form is voluntary. Submitting the Annual Immunization Status Report is mandatory for schools and child care centers in New Jersey. The form is a critical tool for the Department of Health to assess immunization coverage and ensure that children in the state are protected against vaccine-preventable diseases.
  • Data on transfer students is not needed. There's a specific section on the form for reporting the immunization status of transfer students from out-of-state or out-of-country. This information is crucial for maintaining up-to-date immunization records and ensuring all students meet New Jersey's vaccination requirements.
  • The report is only focused on child care centers. While child care centers are indeed required to submit this report, it is equally important for schools with students in elementary and secondary levels to provide their data. The form captures information across different age groups and educational settings.
  • Only new students need to be reported. The form requires information on all pupils enrolled in entry-level grades, grade 6, and transfer students. It's not limited to students newly enrolled in the school or center.
  • Personal information about the students is required. The form focuses on aggregate data related to immunization status and does not ask for personally identifiable information about individual students. It's designed to respect privacy while ensuring compliance with immunization regulations.

Understanding these aspects of the New Jersey Annual Immunization Status Report form helps clarify its purpose and importance in promoting public health within the educational system. By dispelling these misconceptions, schools and child care facilities can more effectively contribute to state-wide immunization efforts.

Key takeaways

When tackling the NJ Annual Immunization Report form, awareness and precision are vital. Begin by understanding the specific requirements laid out in the form. This includes the accurate documentation of immunization statuses for various groups such as entry-level grades, grade 6 pupils, transfer students, and, in specific cases, pre-K and childcare facility attendees. The primary goal is to ensure compliance with New Jersey’s immunization mandates, highlighting the importance of public health and safety within educational environments. Below are key takeaways for efficiently completing and utilizing this essential document:

  • Accuracy is paramount: Inputting the exact numbers for pupils in compliance with immunization requirements, alongside those with provisional admittance, medical or religious exemptions, and unknown status, is critical for the integrity of the report.
  • Understanding different categories: The form segregates data into distinct categories such as pre-K, kindergarten, and grade 6, alongside transfer students. Special attention is needed to accurately report for each specific group, especially noting the differentiation between grade 1 students and others.
  • Comprehensive coverage: Ensure that all enrolled students over the age of 2 months are accounted for in childcare facilities. The form seeks to capture a complete snapshot of immunization coverage, underscoring the importance of inclusivity in reporting.
  • Participation in supplementary surveys: The form also offers an opportunity to contribute to the Influenza Vaccine Implementation Survey (IVIS), aiming to assess vaccine compliance and effectiveness among preschool-aged children. This optional survey underscores the state's commitment to broader public health initiatives beyond basic immunization tracking.

Overall, the NJ Annual Immunization Report form serves as a critical tool in maintaining public health standards within educational settings. By ensuring thorough and accurate completion, schools and childcare facilities play a pivotal role in safeguarding community health, particularly among younger populations. Compliance with these requirements not only fulfills a legal obligation but also contributes significantly to the statewide effort to prevent vaccine-preventable diseases.

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