Annual Immunization Report Worksheet Preschool

Annual Immunization Report Worksheet

Preschool - Childcare

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.r[email protected]. DOH 348-416 October 2023

Schools, preschools, and childcares are required to submit an immunization status report to the Department of

Health by November 1 of each year. WAC 246-105-060.

For the 2023-2024 School Year the report will be due December 1, 2023

Reporting is required for:

• Licensed child care center with 13 or more children

• Preschool located at a public or private school

• Head Start, ECEAP programs

Reporting is optional for:

• Licensed family home child care with 12 or fewer children

• Private preschools not located at a public or private school

• Co-Op preschool

Do not report any information on children in childcare attending school in Transitional Kindergarten through 12

grades. The immunization status of these children will be reported by their public or private school.

Instructions for Transitional Kindergarten through 12

grade reporting are available on the Public and Private K-12

Schools Immunization Reporting | Washington State Department of Health webpage.

Reporting Options

Submit annual report data by using one of the following methods:

School Module – Preferred Reporting Method

An active user of the School Module does not have to file a report if they keep their roster up-to-date

and enter missing immunization dates and exemptions. The Department of Health will generate the

report using the School Module data. For more information about the School Module, please visit:

www.doh.wa.gov/schoolmodule.

Direct Reporting

Direct reporting involves gathering immunization data and entering it into an online reporting form,

which is submitted to the Department of Health. Follow the instructions in the next section to gather the

immunization information you need to report.

Annual Immunization Report Worksheet

Preschool - Childcare

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.r[email protected]. DOH 348-416 October 2023

Immunization Information Needed to Complete the Report

Use these instructions and worksheet to gather the information you will need to complete your annual

immunization report. The Immunization Status Report is a snapshot in time. Complete the information as it is on the

day you are compiling your report. The Department of Health is aware enrollment and immunization status of

students changes over time. You do not need to update information that has changed after you filed the report.

Preschool or Child Care General Information

You will need:

Name of Preschool or childcare:

Preschool public and private – Use the 4-digit OSPI number:

(To find this number go to https://eds.ospi.k12.wa.us/DirectoryEDS.aspx)

Licensed Child/Day Care – Use the license number from DCYF:

(Contact DCYF if you cannot find this number)

Physical address of the facility (not a PO Box)

Street: City:

State: WA Zip: County:

Facility email:

Your Name:

Phone #: Your email:

Age range of children in your preschool or childcare: from to

A: Total Number of Children Enrolled

Determine the total number of children enrolled in the preschool or childcare center.

Do not include children in childcare who are attending school in Transitional Kindergarten-12

grades.

Their status will be reported by their school.

Number of Children Enrolled

Annual Immunization Report Worksheet

Preschool - Childcare

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.r[email protected]. DOH 348-416 October 2023

B: Overall Immunization Status of Each Child

Determine each child’s immunization status on the day you are gathering the data. Use the child’s Certificate of

Immunization Status (CIS) and, if applicable, the Certificate of Exemption (COE) to determine the child’s overall

immunization status. The immunization requirements can be found in the Immunization Requirements section of

the School and Child Care Immunization website www.doh.wa.gov/SCCI.

For the annual report, each child can only have one overall immunization status. This means a child must be

categorized into one status even though a child could be complete for some required immunizations, conditional or

out of compliance for others, and exempt for still others. Use the definitions below to categorize each child.

• A child is COMPLETE if they have a CIS on file and have documented immunity to all of the required vaccine-

preventable diseases. Documented immunity includes vaccination at the appropriate ages and intervals or

by health care provider documentation of immunity by antibody titer or disease history.

• A child is OUT OF COMPLIANCE if they do not have documentation of immunity for any one or more of the

diseases for which documentation of immunization is required, and they are not in a temporary conditional

period, and they do not have a completed COE exempting them from the requirement for immunization

against the disease/s missing documentation of immunity.

• A child is EXEMPT if they have a completed COE for any one or more of the immunization requirements and

are not out of compliance for any other of the immunization requirements.

• A child is CONDITIONAL if they are in the process of obtaining documentation of immunity within the

allowed timeframes. They cannot be out of compliance or have an exemption for any other of the diseases

for which full immunity is required. Conditional status is defined as a child missing the required

documentation of immunity who is waiting for the next dose in a vaccination series. These children are given

30 days after their vaccination due date to turn in immunization paperwork. Conditional status continues

until all of the doses in the series are complete. If the conditional time period expires without providing

documentation of the vaccine dose or a completed COE, then the child’s status changes to out of

compliance.

For example, if a child is conditional for polio, has an exemption for Hepatitis B, is out of compliance for varicella

and complete for all of the other required immunizations then the Overall Status of the child is Out of

Compliance.

Using the definitions above complete the table below:

Each child can only have one overall status.

Complete

Out of

Compliance

Conditional

Exempt

Total

The total must equal the total children

enrolled reported in section A above.

Annual Immunization Report Worksheet

Preschool - Childcare

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.r[email protected]. DOH 348-416 October 2023

C: Children with Exemptions

Count the number of children in each category who have a personal/philosophical, medical, religious, or a religious

membership exemption for one or more of the immunization requirements. A personal/philosophical exemption

may not be used to exempt a child from the measles, mumps, and rubella immunization requirement.

Count the number of CHILDREN with each type of exemption below.

In this section, children can be counted more than once if they have more than one type of exemption.

A type of exemption is listed as personal/philosophical, medical, religious, or religious membership.

Do not count multiple vaccine exemptions in the same category for the same child.

For example:

• If a child has personal exemptions for Hepatitis B and Polio, and a medical exemption for Varicella, mark

them as one child with personal exemption(s) in the personal exemption category and one child with

medical exemption(s) in the medical exemption category.

• If a child has a religious exemption to Pertussis and Measles and a medical exemption to Mumps count them

as one child with religious exemption(s) in the religious exemption category and one child with medical

exemption(s) in the medical exemption category.

• If these two children are the only children with exemptions, the table below would look like this:

Type of Exemption

Personal or

Philosophical

Medical

Religious

Membership

Enter the number of CHILDREN with each type of exemption below.

Type of Exemption

Personal or

Philosophical

Medical

Religious

Membership

Annual Immunization Report Worksheet

Preschool - Childcare

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.r[email protected]. DOH 348-416 October 2023

D: Status of Specific Immunization Requirements

Count the number of children who have a status of complete, conditional, out of compliance or exempt status for

each of the required school immunizations.

• COMPLETE: Count the disease immunity as ‘complete’ if the child has documented immunity to the disease.

Documented immunity includes vaccination at the appropriate ages and intervals or by health care provider

documentation of immunity by antibody titer or history of disease.

• EXEMPT: Count the disease immunity as ‘exempt’ if the child has a completed COE exempting them from

the requirement for full immunization against the disease, and they do not have documentation of

immunity to the disease.

• CONDITIONAL: Count the disease immunity as ‘conditional’ if the child is in the process of obtaining

documentation of immunity within the allowed timeframes. See the definition in section B for more

information.

• OUT OF COMPLIANCE: Count the disease immunity as ‘out of compliance’ if the child does not have

documentation of immunity to the disease, and they are not in a temporary conditional period, and they do

not have a completed Certificate of Exemption (COE) exempting them from the requirement for full

immunization against the disease.

Enter the total immunization status of each disease for all children. *Count all children 5 years old and older as

Complete for PCV and Hib, even if they have no PCV or Hib vaccine doses or have an exemption on file. PCV and Hib

immunity is not required at 5+ years of age.

Each disease can only have one immunization status per child.

Number of CHILDREN

whose disease immunization status is

Diphtheria

Tetanus

Pertussis

Polio

Measles

Mumps

Rubella

Hepatitis B

Varicella

*Pneumococcal

*Hib

Complete

Out of Compliance

Conditional

Exempt – Personal/Philosophical

Not allowed for Measles, Mumps or Rubella

Exempt - Medical

Exempt - Religious

Exempt – Religious Membership

Total

Must equal the total number of children

reported in the enrollment section.

Annual Immunization Report Worksheet

Preschool - Childcare

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.r[email protected]. DOH 348-416 October 2023

Data Quality Check

Review the table above for the following data quality checks:

• The number of children Out of Compliance in Table B cannot be less than the number of children Out of

Compliance for any one of the diseases in Table D. For example, if 2 children are Out of Compliance for Polio

in Table D, then at least 2 children must have an Overall Status of Out of Compliance in Table B.

• The number of children Exempt in Table C cannot be less than the number of children with that type of

exemption for any one of the diseases in Table D. For example, if 2 children have a medical exemption for

Polio in Table D, then at least 2 children must have a medical exemption in Table C.

E: Exclusion

Does your preschool or childcare exclude children who are out of compliance with the State immunization

requirements in accordance with RCW 28A.210.120?

Yes ☐ No ☐

Turn in the Report

You now have the information you need to complete the report.

• Go to the Survey link on the Preschool and Child Care Immunization Status Reporting web page:

https://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/ChildCareStatusReporting

• Enter your facility and contact information.

• Use the information you wrote on this worksheet and enter it in the same fields on the online report. Do

not leave any blanks, enter zero if applicable.

• Double check that the totals equal enrollment where required.

• Correct any error messages.

• Click the submit button to send.

Additional Reporting Resources

Preschool and Child Care Immunization Status Reporting web page:

https://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/ChildCareStatusReporting

School Immunization Status Reporting web page:

https://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/SchoolStatusReporting

School and Child Care Immunization webpage: www.doh.wa.gov/SCCI : Immunization Requirements

Email questions about reporting to [email protected]v.