* Required Fields

*Name of School/Child Care Center
* *

*ASR School ID
*

*Type of School

Public

Non-Public

*

*Grades In School
From: * To: *

*Total School Enrollment

* *

*Facility Mailing Address
* *

*City

* *

*County
Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Select County

*

*School District
* *

*School Contact Person

* *

*Telephone Number
* *

*Email

* *

Select and complete the table(s) respective to the grade(s) you are auditing. Please reference the IMM-15 audit instructions to assist you.

Note: Compliance Rate will be automatically calculated on the summary page. 

School not audited due to COVID-19 pandemic

No grades/transfer students subject to auditing

Child Care/Preschool

Kindergarten/Grade 1

Grade 6

Transfers (Any Grade)

Spec.Ed/Unassigned Grades

Comments

Documentation Problem

Immunization Deficiency

Lack of Enforcement

Other Problem

Recommendations

Invalid characters in Comments

Local Health Department Auditor Information

*Name of Reviewer

*

*Auditing Agency

*

*Telephone Number

* *

*Email Address

* *