Daycare Provider Vaccination Assessment Form
Please complete this assessment to provide your current vaccination status and readiness for work in daycare settings.
Full Name
*
First Name
Last Name
Please indicate your vaccination status for the following vaccines.
*
Rows
Received
Not Received
Unsure
MMR (Measles, Mumps, Rubella)
1
2
3
DTaP (Diphtheria, Tetanus, Pertussis)
4
5
6
Polio
7
8
9
Hepatitis B
10
11
12
Varicella (Chickenpox)
13
14
15
Are all your required vaccinations up to date for working in a daycare setting?
*
Yes
No
Unsure
How confident do you feel in your current vaccination status for working with children?
*
1
2
3
4
5
In the past month, have you experienced any symptoms of contagious illness (e.g., fever, cough, rash)?
*
No symptoms
Mild symptoms (not diagnosed)
Symptoms and diagnosed by a physician
How likely are you to seek medical advice if you develop symptoms relevant to daycare work?
*
Not likely
1
2
3
4
Very likely
5
1 is Not likely, 5 is Very likely
How comfortable do you feel working in a daycare environment given your current health status?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Please rate your understanding of recommended infection control practices in daycare settings.
*
1
2
3
4
5
Have you had any known exposure to contagious diseases in the last 30 days?
*
No
Yes, at work
Yes, outside of work
How prepared do you feel to return to work in a daycare setting?
*
Not prepared
1
2
3
4
Fully prepared
5
1 is Not prepared, 5 is Fully prepared
Submit Assessment
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