Free F-04002 - Wisconsin


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Date: June 29, 2009
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State: Wisconsin
Category: Health Care
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http://dhs.wisconsin.gov/forms/F0/F04002.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Public Health F-04002 (Rev. 08/08)

STATE OF WISCONSIN s. 252.04, Wis. Stats.

SCHOOL REPORT TO LOCAL HEALTH DEPARTMENT
Wisconsin State Statute 252.04 requires that all students through grade 12 who do not submit waivers must present evidence of having received at least the first dose of each vaccine required for their grade within 30 school days of admission and the second dose of DTP/DTaP/DT/Td, Polio, MMR, Hepatitis B and varicella vaccines within 90 school days of admission. Evidence of the third and fourth doses (if required for their grade) of DTP/DTaP/DT/Td, Polio and the third dose of Hepatitis B vaccines must be submitted within 30 school days of the beginning of the next school year. Schools must report to the local health department the compliance by students each year by the 40th school day. ________________________________ _______________________________ Telephone I.D. Number for Address Label ______________________________ School District

________________________________________________ _______________________________________________ Principal Person Completing Form _________________________________________________________________________________________________ Name of School (as listed on label) _________________________________________________________________________________________________ Address ____________________________________________ ___________________ ________________________________ City/Town Zip County COMPLETE BOTH PARTS A AND PART B (Part B is on reverse) PART A INSTRUCTIONS: Indicate how many students fall into each category (1 through 7) in the grade groupings below. The sum of these categories (row 8) must equal the enrollment for the grade(s) in that column. List students in rows 2 through 7 in Part B. Mail to your local city or county health department, not the Wisconsin Department of Health Services. Do not delay completion of this report, submit promptly.

List Number of Students (1) (2) Who meet all minimum requirements In Process (first dose within 30 school days and second dose within 90 school days) Behind Schedule (missed deadline for first, second, or final doses of vaccine) With no record on file With health waiver With religious waiver With personal conviction waiver TOTAL (must = enrollment for grades included in the column)

Pre-Kindergarten

Kindergarten

Grades 1-12

TOTAL

(3)*

(4)* (5) (6) (7) (8)**

*Names of these students are to be reported to the district attorney and/or may be excluded. **Total Row 8 = Total of Last Column = Enrollment of School

F-04002 (Rev. 08/08)

PART B

Page 2

Instructions: List all students from Part A, rows 2 through 7 in ascending grade order, include date of birth, grade level, and vaccine(s) received to date. Enter "0" if no vaccine was received. Use extra sheets if necessary. For student(s) BEHIND SCHEDULE or NO RECORD (Part A, rows 3 & 4) enter date student(s) will be reported to the District Attorney. For student(s) IN PROCESS or WAIVERS (Part A, rows 2,5,6 & 7) check appropriate box, `In Process', H=Health Reasons, R=Religious Reasons, and PC=Personal Conviction. Under Varicella indicate total doses received or "D" for disease. Note: If a separate list is maintained of students who are IN PROCESS of receiving only Varicella vaccine and/or BEHIND SCHEDULE in receiving only Tdap vaccine, it is not necessary to list these students on Part B. For MMR, if first dose was received before the student's first birthday, do not count the dose. Do not include a history of disease, only the vaccine.
Name Date of Birth Date of Admission To WI School Non-Compliant / Report to District Attorney Behind No Record Schedule Mark (X) In Process H R P C DTP / DTaP / DT / Td Total Doses Last Dose Date Polio Total Doses Last Dose Date Hep B Total Doses MMR Total Doses Varicella Total Doses or D=Disease Tdap Dose Date

Grade