New Jersey Department of Health
Vaccine Preventable Disease Program
PO Box 369, Trenton, NJ 08625-0369
Annual Immunization Status Report

The Annual Status Report (ASR) is due February 1 of the respective academic year. If you have any questions, please contact the Vaccine Preventable Disease Program at 609-826-4860.

  • ASR FAQs [pdf 27k]
  • Minimum Immunization Requirements for School Attendance (K-12) [pdf 27k]
  • Minimum Immunization Requirements for Childcare/Preschool [pdf 25k]
* Required fields
*ASR School ID:     Find your School ID 
Please review the School Information below to ensure accuracy.
*Is your school information correct?
(If no, please click "No" to edit your
school information)
 
School Information
*County:      
*Name of School / Child Care Facility:    
Mailing Address
*Street:     
*City:   *Zip:  
Physical School Address (complete only if physical address is different from mailing address)
Street:  
City: Zip:
Contact & Enrollment Information
       
*Name of Person Completing the Form:   Telephone:
* Email Address of Person Completing the Form:  
Name of Principal / Person in Charge: Title:
*Total School / Child Care Center Enrollment (include All Grades):        
*Is your facility Public or Non-Public?:      
*Do you have any students under 60 months of age?      
Required Immunization Survey (excludes Influenza Immunizations)
INSTRUCTIONS:   In the survey below, please select the grade levels at your facility and then indicate the immunization status of all pupils at those levels.


SPECIAL INSTRUCTIONS:
For Child Care facilities: On the Pre-K row of the table below, enter the immunization status of all enrolled children over 2 months of age.
For Grade 1: Do not include data in the grade 1 boxes unless the student is beginning school for the very first time in your school district in grade 1. Include pupils in this row if they either attended Kindergarten outside of your district or you are unsure where they attended Kindergarten.
For Special Education Students: Ungraded special education pupils should be included with the appropriate age cohort class.
For Transfer Students: Includes all students newly transferred into grades 2-5 and 7-12 from out-of- state/country since the submission of last year’s report. High schools are only required to report out-of-state or out-of-country transfers.

What grade levels are housed in your facility? (Please select all that apply).

There will be a separate table for each grade level where you should enter the status of all pupils.
NOTE: This survey excludes Influenza Immunizations.



*Number of Pupils Enrolled **Pupils Meeting All Immunization Requirements (excludes Flu Requirement) + Pupils with Provisional Admittance Pupils with Medical Exemptions Pupils with Religious Exemptions ^ Pupils who are Out of Compliance




*Number of Pupils Enrolled **Pupils Meeting All Immunization Requirements (excludes Flu Requirement) + Pupils with Provisional Admittance Pupils with Medical Exemptions Pupils with Religious Exemptions ^ Pupils who are Out of Compliance




*Number of Pupils Enrolled **Pupils Meeting All Immunization Requirements (excludes Flu Requirement) + Pupils with Provisional Admittance Pupils with Medical Exemptions Pupils with Religious Exemptions ^ Pupils who are Out of Compliance




*Number of Pupils Enrolled **Pupils Meeting All Immunization Requirements (excludes Flu Requirement) + Pupils with Provisional Admittance Pupils with Medical Exemptions Pupils with Religious Exemptions ^ Pupils who are Out of Compliance




*Number of Pupils Enrolled **Pupils Meeting All Immunization Requirements (excludes Flu Requirement) + Pupils with Provisional Admittance Pupils with Medical Exemptions Pupils with Religious Exemptions ^ Pupils who are Out of Compliance

 

* Optional – Record the total number of pupils enrolled in Pre-K/Childcare, Kindergarten, and Grade 6. For Grade 1 and Transfers only, record the number of pupils that required to be entered on the survey (see Special Instructions above).

** Meeting All Immunization Requirements – Excludes pupils with Provisional Admittance, Medical Exemptions, or Religious Exemptions.

+ Provisional Admittance - Students who have received at least one dose of each required age-appropriate vaccine and are 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 – Children who either do not meet criteria for the other categories or whose status is unknown.  



Are you willing to complete the Influenza Vaccine Implementation Survey?

Influenza Vaccine Implementation Survey (IVIS)

INSTRUCTIONS: 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.

 

Total # of Pupils between ages 6-59 mos. Total # of Pupils between ages 6-59 mos. who received flu vaccine by December 31st Total # of Pupils between ages 6-59 mos. with a Religious Exemption for flu vaccine Total # of Pupils between ages 6-59 mos. with a Medical Exemption for flu vaccine Total # of Pupils between ages 6-59 mos. who are Out of Compliance
                                                                                   
Please click on Submit, print out your submission, and send a copy to your local health department.