2024 Child Care Providers Immunization Survey

2024 Child Care Providers Immunization Survey
Regulated child care programs in Vermont, including registered and licensed family child care homes and center-based programs, public school preschool programs, and Head Start programs, must submit an immunization survey for the children enrolled once per year by December 31st.

Important! This immunization survey is required by child care licensing regulation rule 5.1.4. Programs that do not submit by December 31st will have a violation cited on rule 5.1.4. No extensions to complete the report will be approved.

Resources
- Please visit the Immunization Information for Child Care and School Providers page for more information.
- Immunizations documenting and reporting requirements are available through the Immunization Registry Guide for Child Care Programs and Immunization Reporting Fact Sheet.
Questions
- For help completing this form, please contact Debra Clark at debra.clark@vermont.gov or at 802-904-3144.
- For questions about the immunization registry or to get a password/sign up, contact the Immunization Registry staff at 1-888-688-4667 or email IMR@vermont.gov.
- For more information about the required immunizations or records, please contact local health office or email the immunization program at AHS.VDHImmunizationProgram@vermont.gov.
Helpful Tips
- Only submit this survey once per program site.
- View a printable version of this survey. You must submit the survey online; the print version is available to help you prepare the information for submission.
- If your program does not serve certain age groups listed in the survey, please enter zeros in those fields.
- 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.
- Every cell requires an answer. Enter a zero (0) instead of leaving a cell empty.
- If you get a red error message, correct it before moving forward. If you need help fixing an error, please contact Debra Clark at debra.clark@vermont.gov or at 802-904-3144.
- Once you have clicked Submit, the email address you entered in the report will receive an emailed copy of your submitted information. The email is your confirmation that we received the report. If you do not receive this confirmation, please contact Debra Clark at debra.clark@vermont.gov or at 802-904-3144.
Name of Child Care Program*
As listed on the license certificate.
Child Care License Certificate Number*
As listed on the license certificate.
Child Care Facility Contact Information
Person Completing this Form:*

First NameLast Name
Contact Person (if different from above)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Phone Number*

Area CodePhone 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 the 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.
IMPORTANT!! If you experience issues submitting this survey (e.g., error messages or submit button not displaying), please complete the PDF form at https://outside.vermont.gov/dept/DCF/Shared%20Documents/CDD/Safety/CC-Immunization-Survey-Sample.pdf and email it to AHS.DCFCDDInfo@vermont.gov.
Should be Empty:

2024 Child Care Providers Immunization Survey

Resources

Questions

Helpful Tips

Child Care Facility Contact Information

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