Eleventh Grade Immunization Survey Logging
Demographics

Eleventh Grade Immunization Survey

(902 KAR 2:055)

The following questions will pertain to the Eleventh Grade only and will follow the same format as the paper version as directed by Commonwealth legislation (902 KAR 2:055). You may use the survey worksheets or Infinite Campus Immunization Compliance Summary Report and Dose Count Totals to complete this survey as instructed in previous years.


All questions need to be completed in their entirety (as indicated with a red asterisk *). Once submitted, your answers will be recorded and your school will be in compliance with 902 KAR 2:055 for the Eleventh Grade reporting requirement. You will only be contacted if the Immunization Program detects a problem with the numbers that are submitted, or if your school is randomly selected for the data validation/audit in the spring. If you have questions regarding the survey please contact Taylor Miller at taylor.miller@ky.gov .


This survey will be open until December 31st, 2020 at 11:59pm EST.


IMPORTANT! Please only submit a survey once for your school. If you have edits or need to correct a survey previously submitted please email taylor.miller@ky.gov to update.


Name of Person Completing This Form:
*
Credentials:
Date:
*

County:
*
School District:
*

*If a private school or daycare please use “Private School” or “Daycare” as your District Name.

School/Facility Name:
*
Address:
*
 
City:
*
Zip Code:
*
Phone Number:
Email:
*

Type Of Facility:

*

1. Total Number Of Children Enrolled:
*

2. Total Number of Homeschool Children Enrolled in School Activities:
*

Grand Total From Lines 1 and 2:
*
Immunization Certificate and Exemption

NOTE: Information for the following should be obtained from the Commonwealth of Kentucky Immunization Certificate for each enrolled child.


a. How many children have a current/provisional certificate on file?
*

*Do NOT include students who have a medical or religious exemption on file in this total


b. How many children have a certificate to exempt from immunizations for medical reasons?
*

c. How many children have a certificate to exempt from immunizations for religious reasons?
*

d. How many children have an expired certificate on file?
*

e. How many children do not have any immunization certificates on file?
*

STOP: The total of a+ b+ c+ d+ e MUST = the Grand Total number listed in the above section.

Vaccine Dose Summary
Enter the number of children that have received 1 dose of the Tdap vaccine.
*

Enter the number of children that have received a complete Meningococcal series.
*

Count any child who has received the MenACWY 2-dose series OR one dose at or after 16 years of age as having a complete series


Enter the number of children that have received the complete series of the Hepatitis B vaccine.
*

Count any child who has received the 3-dose infant series OR the 2-dose adolescent/adult series as having a complete series.


Enter the number of children that have received 2 doses of the MMR vaccine.
*

Enter the number of children that have had 2 doses of Varicella:
*

Enter the number of children that have had chickenpox and 0 doses of Varicella:
*

Enter the number of children that have had chickenpox and 1 dose of Varicella:
*

Enter the number of children that have received 2 doses of the Hepatitis A vaccine.
*
 
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