Childcare Coverage Assessment Survey
including Head Start

demographics

Grantee Project Area
School Year
Program manager
Prepared by

school point of contact

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
 

 

scope of the report

Childcare Facilities Surveyed




Type of Childcare facility:





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.)




section ii. report parameters

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: 
 
From age: 
 To age: 
 
Date assessment started: 
Date assessment ended: 
 
 
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)?

 
10. Childcare related vaccine exemption comments: 


vaccine information for childcare

  • 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.
         
 
Vaccine Is this vaccine required for Childcare entry? Indicate # of doses for UTD status. Number of surveyed children who were considered UTD.
 
11. Polio(4)(3+)
12. DTP/DTaP/DT(3) (4+)
15. Measles(2) (1)
16. Mumps(2) (1)
17. Rubella(2) (1)
18. Haemophilus influenzae type b (HIB)(3+)
19. Hepatitis B Vaccine (Hep B) (3+)
20. Varicella (1)
21. Pneumococcal Conjugate Vaccine (PCV) (4+)
22. Hepatitis A (Hep A) (3)
23. Rotavirus (2)
 
 
(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?

 
 
 

cdc contacts

Report/Content Issues:Cindi Knighton | Carol Stanwyck
Technical/Website Issues:Robert Avey

 

Safer, Healthier People

Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435		 FirstGovDHHS Department of Health
and Human Services