Worksheet for Children 24 Months to First Day of Kindergarten
(Birth dates Oct. 1, 2014, and earlier)
Do not submit this worksheet to MDH.
• Write the name of each child in this age group in one of the spaces in the “Name” column. For each child, mark his or her vaccination status for each vaccine. Count the number of marks in each column
at the bottom and transfer the count to your report form. Do not submit this worksheet to MDH.
• A child who is exempt must have a statement on file in accordance with Minn. Stat. §121A.15.
• A child who is exempt from a vaccine requirement should be counted in the NM (non-medical exemption) or ME (medical exemption) column for that vaccine even if the child has received some doses
of the vaccine.
• Each child should only have one check mark for each vaccine.
Number in column
Hepatitis A
1D
No
Dos
es
ose
NM (Mee
ts R
equ
ME
irem
ent
)
Varicella
(Chickenpox)
No
Dos
1 D es
ose
(Me
His
e
tor
y o ts Req
f Di
NM
sea uirem
ent
se
ME
)
ME
No
Dos
1 D es
ose
NM (Me
ets
Req
ui
rem
ent
)
ent
)
irem
ets
Req
u
ME
No
Dos
1 D es
ose
NM (Me
es
Dos
es
3D
ose (In Pr
NM s (Me ogres
s)
ets
Req
ME
uire
Dos
1-2
No
Measles,
mumps, rubella
(MMR)
Haemophilus
influenzae
type b (Hib)
Polio
(IPV or OPV)
me
nt)
ent
)
Diphtheria,
tetanus,
pertussis (DTaP)
es
Dos
es
4D
ose (In Pro
gre
NM s (Me
ss)
ets
R
e
ME
qui
rem
Dos
1-3
No
1-2
Name
No
Dos
es
Dos
es
3D
ose (In Pr
NM s (Me ogress
ets
)
Req
ME
uire
me
nt)
Hepatitis B
8/16