Name of School:
* must provide value
Type of School:
* must provide value
Public
Private
Street Address:
* must provide value
City:
* must provide value
Zip Code:
* must provide value
County:
* must provide value
Person Completing Survey:
* must provide value
Email Address:
* must provide value
My school has assigned all students, including exemptions, in ImmPRINT.:
* must provide value
Yes
No
If yes, you have completed the survey. Click "Submit"
If you would like to enroll or have questions about ImmPRINT, email immprint@adph.state.al.us
Check all grades that apply for your school.
* must provide value
K3
K4
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Please provide the total number for each of the questions below.
K3 Total Enrollment
* must provide value
K3 Unexpired Certificate of Immunization (COI)
* must provide value
K3 Certificate of Medical Exemption (Ex):
* must provide value
K3 Partial Medical Ex & COI:
* must provide value
K3 Certificate of Religious Ex
* must provide value
K3 Partial Religious Ex & COI
* must provide value
K3 Expired Certificate of Immunization (COI)
* must provide value
K3 No Record on File
* must provide value
K4 Total Enrollment
* must provide value
K4 Unexpired Certificate of Immunization (COI)
* must provide value
K4 Certificate of Medical Exemption (Ex):
* must provide value
K4 Partial Medical Ex & COI:
* must provide value
K4 Certificate of Religious Ex
* must provide value
K4 Partial Religious Ex & COI
* must provide value
K4 Expired Certificate of Immunization (COI)
* must provide value
K4 No Record on File
* must provide value
K5 Total Enrollment
* must provide value
K5 Unexpired Certificate of Immunization (COI)
* must provide value
K5 Certificate of Medical Exemption (Ex):
* must provide value
K5 Partial Medical Ex & COI:
* must provide value
K5 Certificate of Religious Ex
* must provide value
K5 Partial Religious Ex & COI
* must provide value
K5 Expired Certificate of Immunization (COI)
* must provide value
K5 No Record on File
* must provide value
1st Grade Total Enrollment
* must provide value
1st Grade Unexpired Certificate of Immunization (COI)
* must provide value
1st Grade Certificate of Medical Exemption (Ex):
* must provide value
1st Grade Partial Medical Ex & COI:
* must provide value
1st Grade Certificate of Religious Ex
* must provide value
1st Partial Religious Ex & COI
* must provide value
1st Expired Certificate of Immunization (COI)
* must provide value
1st No Record on File
* must provide value
2nd Grade Total Enrollment
* must provide value
2nd Grade Unexpired Certificate of Immunization (COI)
* must provide value
2nd Grade Certificate of Medical Exemption (Ex):
* must provide value
2nd Grade Partial Medical Ex & COI:
* must provide value
2nd Grade Certificate of Religious Ex
* must provide value
2nd Partial Religious Ex & COI
* must provide value
2nd Expired Certificate of Immunization (COI)
* must provide value
2nd No Record on File
* must provide value
3rd Grade Total Enrollment
* must provide value
3rd Grade Unexpired Certificate of Immunization (COI)
* must provide value
3rd Grade Certificate of Medical Exemption (Ex):
* must provide value
3rd Grade Partial Medical Ex & COI:
* must provide value
3rd Grade Certificate of Religious Ex
* must provide value
3rd Partial Religious Ex & COI
* must provide value
3rd Expired Certificate of Immunization (COI)
* must provide value
3rd No Record on File
* must provide value
4th Grade Total Enrollment
* must provide value
4th Grade Unexpired Certificate of Immunization (COI)
* must provide value
4th Grade Certificate of Medical Exemption (Ex):
* must provide value
4th Grade Partial Medical Ex & COI:
* must provide value
4th Grade Certificate of Religious Ex
* must provide value
4th Partial Religious Ex & COI
* must provide value
4th Expired Certificate of Immunization (COI)
* must provide value
4th No Record on File
* must provide value
5th Grade Total Enrollment
* must provide value
5th Grade Unexpired Certificate of Immunization (COI)
* must provide value
5th Grade Certificate of Medical Exemption (Ex):
* must provide value
5th Grade Partial Medical Ex & COI:
* must provide value
5th Grade Certificate of Religious Ex
* must provide value
5th Partial Religious Ex & COI
* must provide value
5th Expired Certificate of Immunization (COI)
* must provide value
5th No Record on File
* must provide value
6th Grade Total Enrollment
* must provide value
6th Grade Unexpired Certificate of Immunization (COI)
* must provide value
6th Grade Certificate of Medical Exemption (Ex):
* must provide value
6th Grade Partial Medical Ex & COI:
* must provide value
6th Grade Certificate of Religious Ex
* must provide value
6th Partial Religious Ex & COI
* must provide value
6th Expired Certificate of Immunization (COI)
* must provide value
6th No Record on File
* must provide value
7th Grade Total Enrollment
* must provide value
7th Grade Unexpired Certificate of Immunization (COI)
* must provide value
7th Grade Certificate of Medical Exemption (Ex):
* must provide value
7th Grade Partial Medical Ex & COI:
* must provide value
7th Grade Certificate of Religious Ex
* must provide value
7th Partial Religious Ex & COI
* must provide value
7th Expired Certificate of Immunization (COI)
* must provide value
7th No Record on File
* must provide value
8th Grade Total Enrollment
* must provide value
8th Grade Unexpired Certificate of Immunization (COI)
* must provide value
8th Grade Certificate of Medical Exemption (Ex):
* must provide value
8th Grade Partial Medical Ex & COI:
* must provide value
8th Grade Certificate of Religious Ex
* must provide value
8th Partial Religious Ex & COI
* must provide value
8th Expired Certificate of Immunization (COI)
* must provide value
8th No Record on File
* must provide value
9th Grade Total Enrollment
* must provide value
9th Grade Unexpired Certificate of Immunization (COI)
* must provide value
9th Grade Certificate of Medical Exemption (Ex):
* must provide value
9th Grade Partial Medical Ex & COI:
* must provide value
9th Grade Certificate of Religious Ex
* must provide value
9th Partial Religious Ex & COI
* must provide value
9th Expired Certificate of Immunization (COI)
* must provide value
9th No Record on File
* must provide value
10th Grade Total Enrollment
* must provide value
10th Grade Unexpired Certificate of Immunization (COI)
* must provide value
10th Grade Certificate of Medical Exemption (Ex):
* must provide value
10th Grade Partial Medical Ex & COI:
* must provide value
10th Grade Certificate of Religious Ex
* must provide value
10th Partial Religious Ex & COI
* must provide value
10th Expired Certificate of Immunization (COI)
* must provide value
10th No Record on File
* must provide value
11th Grade Total Enrollment
* must provide value
11th Grade Unexpired Certificate of Immunization (COI)
* must provide value
11th Grade Certificate of Medical Exemption (Ex):
* must provide value
11th Grade Partial Medical Ex & COI:
* must provide value
11th Grade Certificate of Religious Ex
* must provide value
11th Partial Religious Ex & COI
* must provide value
11th Expired Certificate of Immunization (COI)
* must provide value
11th No Record on File
* must provide value
12th Grade Total Enrollment
* must provide value
12th Grade Unexpired Certificate of Immunization (COI)
* must provide value
12th Grade Certificate of Medical Exemption (Ex):
* must provide value
12th Grade Partial Medical Ex & COI:
* must provide value
12th Grade Certificate of Religious Ex
* must provide value
12th Partial Religious Ex & COI
* must provide value
12th Expired Certificate of Immunization (COI)
* must provide value
12th No Record on File
* must provide value
Please call Immunization Division at 1-800-469-4599 if you have a question about this survey.
Return SURVEY by Sunday, November 15, 2020
Submit
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