Name of School:
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Type of School:
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Public
Private
Street Address:
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City:
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Zip Code:
* must provide value
County:
* must provide value
Person Completing Survey:
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Email Address:
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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
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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