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OR Medical Card Sections F, G, and H

Sections F, G, and H Layout

Instructions for Primary Review Summary Page 4 — Sections F, G, and H

Complete this form when you have all the student records updated, no later than 12 days after Exclusion Day. Fill out this form even if all the records have not yet been updated. 

Only count the students you included on the Section A report who are still enrolled. Do not count new students. If students have left your school or facility since you turned in the initial report, do not count them in the follow-up report. These students will be counted next year.

If your school has students younger than kindergarten, only report them in Section E.

How many students in grades K-12 were excluded on Exclusion Day?This is the number of students in grades K-12 excluded at the start of school on Exclusion Day. Record the number of children younger than kindergarten who were excluded on Section E, Page 3.
Total enrollmentThis is the total number of students enrolled in grades K-12.
Students not countedStudents who attend more than one school or facility and spend more time at the other site should be included in this number.
Adjusted enrollmentThis is the total enrollment minus the students not counted.
No recordStudents who have no immunization records or exemptions on file should be counted here. If all the records have been updated, this number should be zero.
Medical exemptionsThis is any student that has a temporary or permanent medical exemption that has been approved by the local health department.
Nonmedical exemptionsAny student that has a nonmedical exemption, whether for one or all vaccines, should be counted here. Fill in the number of students with a nonmedical exemption that have documentation from the online vaccine education module and a health care practitioner.
Number with vaccines: DTaP/Tdap, Polio, Varicella, MMR, Measles, Hepatitis B, Hepatitis A, and All

Fill in the number of students who are complete for that vaccine (with the specified number of doses).

In the All category, fill in the number of students that are complete for all the vaccines required at their grade level. Include students with a history of disease or immunity documentation.

Number with nonmedical exemptions: DTaP/Tdap, Polio, Varicella, Measles, Mumps, Rubella, Hepatitis B, Hepatitis A, and All

Fill in the number of students who have a nonmedical exemption for each vaccine. 

In the All category, fill in the number of students who have nonmedical exemptions for every vaccine required for their grade. If a student has both the specified number of vaccines and an exemption for the vaccine, count the child in the vaccine category and do not count the student in the exemption category. In the All category, count the number of students with nonmedical exemptions for all vaccines (and count these children in the individual vaccine categories also).

After you have completed Section H, tear off the back (yellow) copy of the form. This information is also for your records and must be kept for one year. The top (white) copy of this form along with the copies of the other reporting forms need to be turned in to the health department by 12 days after Exclusion Day.  Electronic copies may also be submitted to your local health department.

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