2020 Child Care Providers Immunization Survey

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.
Name of Child Care Program (as listed on the licensed certificate) *
Child Care License Certificate Number *
Child Care Facility Contact Information
Person Completing this Form: *

First Name Last Name
Contact Person (if different from above)

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
Phone Number

Area Code Phone Number

What is the total number of children enrolled in this child care program (as of today)?
Infants (Birth to the second birthday) *
Toddlers (2 years to the third birthday) *
Preschoolers (3 years to 5 year olds who have not yet entered kindergarten) *
School age (Kindergarteners and up) *
Total Children Enrolled
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.

Please indicate the number of children and their current immunization status. *

Number up-to-date with immunizations

Number provisionally admitted

Number with religious exemption

Number with medical exemption

Infants (Birth to 2nd birthday)

Toddlers (2 years to 3rd birthday)

Preschoolers (3 - 5 year olds not in kindergarten)

Number infants current immunization status:
Number toddlers current immunization status:
Number preschoolers current immunization status:
** 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 Hib (Haemophilus influenza type b) *
Total children missing PCV (Pneumococcal) *
Total children missing Hep B (Hepatitis B) *
Total children missing DTaP (Diphtheria, Tetanus, Pertussis) *
Total children missing IPV (polio) *
Total children missing Varicella (Chickenpox) *
Total children missing MMR (Measles, Mumps, Rubella) *
Total Infants, Toddlers and Preschoolers needing immunizations
** 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:

2020 Child Care Providers Immunization Survey

Helpful tips

Child Care Facility Contact Information

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