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Annual Immunization Status Report

The Annual Status Report (ASR) for the 2014-2015 school year is due February 1, 2015. If you have any questions, please contact the Vaccine Preventable Disease Program at 609-826-4861.

arrow ASR FAQs [pdf 27k]
arrow Minimum Immunization Requirements for School Attendance (K-12) [pdf 27k]
arrow Minimum Immunization Requirements for Childcare/Preschool [pdf 25k]
arrow Instructions for Completing the On-Line Annual Immunization Status Report [pdf 25k]

* Required Fields
*School ID: -
*County: Muncipality Code: (not required)
School District:
*Name of School/ Child Care Facility:
If Facility Recently Changed Name, List Previous Name:
Mailing Address:
*City: *Zip Code:
School Address (if different from above)
City: Zip Code:
*Name of Person Completing the Form: *Telephone:
*School Email Address:
Name of Principal/ Person in Charge: Title:
*Total School/Child Care Center Enrollment:
*Elementary/ Secondary School/Child Care Facility: Public Non-Public

The school is responsible for assuring that all pupils are in compliance with the New Jersey Immunization requirements. In the boxes below, enter the status of all pupils in your entry level grade, grade 6, and transfer students (any grade).

  • Child care facilities must enter the immunization status of all enrolled children who are over 2 months of age on the pre-k line
  • If your school has pre-kindergarten classes, enter those children on the pre-k line.
  • If your school has a kindergarten grade, enter those children on the kindergarten line.
  • Do not include data in the grade 1 boxes unless the student is beginning school for the very first time in grade 1.
  • All pupils entering grade 6 record on the grade 6 line.
  • Ungraded special education pupils should be included with the appropriate age cohort class.

Grade Level Not Applicable *Number of Pupils Enrolled **Pupils Meeting All Immunization Requirements +Pupils with Provisional Admittance Pupils with Medical Exemptions Pupils with Religious Exemptions Pupils with Status Unknown
Grade 1:
Grade 6:
***Transfer Students
(Out of State/Country only):

* Optional

** Excluding the flu vaccine requirement. Include data on flu vaccine requirement in the Influenza Vaccine Requirement Survey below.

+ Provisional Admittance - Those students who have received at least one dose of each required age-appropriate vaccine, and is on schedule to receive subsequent doses using minimum intervals. Students who do not meet the provisional definition are considered to be out of compliance. Out of compliance students are not captured on this report and should not be reported under the Provisional category. Students who do not fall into any of the reported categories above will be assumed to be out of compliance.

*** Transfer Students - all students newly transferred into grades K-12 from any out-of state/out-of country school during the reporting time frame of September 1 to December 31.

If you do not have any students under 60 months of age, thank you for completing your Annual Immunization Status Report. Please click on submit and print out your submission.

If you have students under 60 months of age, please consider assisting us in assessing the efficacy of the influenza vaccine requirement. To participate in Influenza Vaccine Implementation Survey (IVIS), please click 'Yes' below. To not participate, please click on 'No'.

Are you willing to complete the IVIS? Yes No

Influenza Vaccine Implementation Survey (IVIS)

As per N.J.A.C. 8:57-4.19, children six months through 59 months of age attending any licensed child care center, or preschool facility shall annually receive at least one dose of influenza vaccine between September 1 and December 31 of each year.

Although the survey is voluntary, we need to evaluate the compliance with and the effectiveness of the influenza vaccination programs for preschool aged children. We appreciate your cooperation in filling out this survey.


Total # of Students between ages 6-59 mos. subject to the influenza requirement Total # of Students who received influenza vaccine by December 31st Total # of Religious Exemptions for influenza vaccine Total # of Medical Exemptions granted for influenza vaccine


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P. O. Box 360, Trenton, NJ 08625-0360
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Last Modified: Thursday, 05-Feb-15 08:46:00