New Jersey Department of Health

Vaccine Preventable Diseases Program

PO 369

Trenton, NJ 08625-0369	Provisional Admission

Student Tracking record
Name of School

Date

Street Address

City

Name of School Administrator

Telephone Number

Name of Student

Date of Birth

Date of Provisional Admittance

CHECK THE DOSE(S) NEEDED AND THE DUE DATE ON THE LINE PROVIDED.

VACCINES	DOSE(S)	VACCINE SCHEDULE
Diphtheria, Tetanus, acellular Pertussis

(INDICATE THE SPECIFIC VACCINE REQUIRED:)

DTaP

DT

Td	1
2
3
4
5
Tdap (Tetanus, diphtheria, acellular Pertussis)

(One dose requirement)	1
Polio

(IPV)	1
2
3
4
Measles, Mumps, Rubella (MMR)	1
2
Haemophilus influenza Type b (Hib)	1
2
3
4
Hepatitis B	1
2
3
Pneumococcal Conjugate (PCV 13)	1
2
3
4
Varicella

(One dose requirement)	1
Meningococcal

(One dose requirement)	1
Influenza

(One dose requirement by December 31)	1
DEFINITION: Provisional admission only applies to multi-dose vaccine requirements - NOT single dose vaccine requirements. Students need to receive a minimum of one dose of each of the required vaccines in order to be provisionally admitted. Pupils must be actively in the process of completing the series and on schedule to receive subsequent doses as rapidly as medically feasible. NJ follows CDC/ACIP Recommended Catch-Up Immunization Schedule. Please see the following link for guidance: http://www.cdc.gov/vaccines/schedules/downloads/child/catchup-schedule-pr.pdf.

Please refer to the NJ Vaccine Preventable Disease Program website to access the immunization regulations and requirements for school attendance, http://nj.gov/health/cd/imm.shtml.

IMM-16

APR 14

IMM-16, Provisional Admission Student Tracking Record

ewhite

2014-04-10

NJDOH