• 2020 Child Care Providers Immunization Survey

  • Regulated child care programs in Vermont, including registered and licensed home programs, center based programs, public school preschool programs and Head Start programs, are required to submit an immunization survey for the children enrolled once per year by December 31st. This immunization survey is required by child care rule 5.1.4. 

    For more information about the immunizations required for child care entry please visit: http://www.healthvermont.gov/immunizations-infectious-disease/immunization/child-care-providers

    Training and information about immunizations documenting and reporting requirements is available here:  http://publish.myudutu.com/published/launch/65232/Course136475/Launch.html

    For help completing the form please call 1-802-241-0816. For more information about the required immunizations please call your local district Department of Health office. A list of contacts is available here: http://healthvermont.gov/hc/imm/index.aspx#designees

  • Helpful tips

    • Only submit this survey once per program site
    • If you need to correct an error please call 1-800-649-2642, ext. 0816 or call 1-802-241-0816 or email heather.mattison@vermont.gov
    • To view a print version of this survey go to: https://dcf.vermont.gov/sites/dcf/files/CDD/Docs/Licensing/Child-Care-Providers-Immunization-Survey-Example-Only.pdf.   This must be submitted online, the print version is available to help you prepare the information for submission
    • Count children who neither meet all vaccine requirements nor have a current exemption as provisionally admitted
    • Count children with documentation of chickenpox disease as equivalent to having varicella vaccine, and up to date
    • If you have questions about specific immunizations or records call your local health office: https://www.healthvermont.gov/local or the immunization program at AHS.VDHImmunizationProgram@vermont.gov
    • If you get a red error message , correct it before moving forward. If you need help correcting an error call 1-802-241-0816.
    • Every cell requires an answer, enter a zero (0) instead of leaving a cell empty
    • Once you have clicked submit, the email address you have entered into the report will receive an emailed copy of the information you have submitted. This is your confirmation that the report was received. If you do not receive this confirmation please call 1-802-241-0816.
  • Child Care Facility Contact Information

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  • What is the total number of children enrolled in this child care program (as of today)? 


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  • Count the number of children that fit into each of the categories below and enter the number in the box next to the category. The number of children in each age category must match the number of children enrolled in that age category above.

    * Hint: Enter a zero if you have no children enrolled in the category.

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  • ** The number of infants indicated in status of immunizations does not match the number of enrolled infants in the previous question.

  • ** The number of toddlers indicated in status of immunizations does not match the number of enrolled toddlers in the previous question.

  • ** The number of preschoolers indicated in status of immunizations does not match the number of enrolled preschoolers in the previous question.

  • Please report the number of children who have NOT been immunized against the vaccines below.

    Include all children missing one or more doses of a required vaccine for any reason: provisional admission, religious exemption, or medical exemption.

  • ** Total children missing any immunization cannot exceed the total number of infants, toddlers and preschoolers enrolled who are provisionally admitted, or have a religious or medical exemption.

  • Should be Empty: