Childcare Coverage Assessment Survey
including Head Start
Grantee Project Area
School Year
Program manager
Prepared by
Primary
Contact
Name
Title
Organization
Address
Address 2
City
State
Zip
Phone
Ext
Fax
Email
Secondary
Contact
Name
Title
Organization
Address
Address 2
City
State
Zip
Phone
Ext
Fax
Email
How were the data for this report collected?
Does the child's vaccination record at the
childcare facility include a provider's signature?
(Provider =
doctor, nurse, clinic, physician assistant, or health department.)
Please fill in the blank with the appropriate
numbers. You can get information on school enrollment from your
department of education. If possible, please include only
children 19 months and older, at time of assessment, who are not in school for
each of the questions in the remainder of the survey.
Age(s) included in report:
1. What is the total number of childcare facilities in
"State Name"
?
2. What is the total number of children enrolled in childcare
in
"State Name" ?
3. Of the total number of facilities in
"State Name"
, how many did you survey?
4. Of the total number of children enrolled in your
facilities, how many children did you survey?
5. How many surveyed children did not have immunization records available to you?
Instructions for completing the exemption section:
Please report permanent exemptions and temporary exemptions separately. If you
are unable to do that, please use the spaces for permanent exemptions to report
total exemptions in each category. Make a note in the comment section
explaining how your reported the exemption data.
6. How many children were exempted from required vaccines for medical reasons?
7. How many children were exempted from required vaccines for religious reasons?
8. How many children were exempted from required vaccines for philosophical reasons?
9. How many children were exempted from required vaccines on a temporary basis (e.g. given 30 days to be up-to-date)?
-
Comments and definitions on reporting vaccine requirements and doses:
-
Up-to-date(UTD) = received the appropriate doses of each vaccine.
-
Include a vaccine in your count whether it was administered individually or
through combination vaccines.
-
The ACIP recommended doses are shown in parentheses beside the vaccine name.
(1) Fully immunized = up-to-date on the antigen or immune
through disease process.
(2) Include this vaccine if administered individually or
through a combination vaccine such as MMR.
(3) 5 doses recommended unless the 4th dose was administered
at >4 years of age.
(4) 4 doses recommended unless the 3rd dose was administered
at >4 years of age.
24. Do you require influenza vaccine for school entry?
25. Do you require influenza vaccine for childcare entry?
Comments:
Is this your final submission of data for this survey?
Report/Content Issues:Cindi
Knighton |
Carol
Stanwyck
Technical/Website Issues:Robert
Avey