Worksheet for Children 16 through 23 Months
(Birth dates Oct. 2, 2014 - June 1, 2015)
Do not submit this worksheet to MDH.
Number in column
Measles,
mumps, rubella
(MMR)
ent
Dos
es
ose
NM (Mee
ts R
equ
ME
irem
1D
No
es
ose
NM (Mee
ts R
equ
ME
irem
Dos
1D
No
Varicella
(Chickenpox)
)
No
Dos
1 D es
ose
(Me
His
e
tor
y o ts Req
f Di
NM
sea uirem
ent
se
ME
)
Haemophilus
influenzae
type b (Hib)
ent
ent
)
Pneumococcal
conjugate vaccine
(PCV)
es
Dos
es
3D
ose (In Pro
s
gre
(Me
NM
ss)
ets
R
equ
ME
irem
1-2
No
Dos
me
nt)
Polio
(IPV or OPV)
No
Dos
1 D es
ose
2 D (In Pr
ose
og
NM s (Me ress)
ets
Req
ME
uire
ent
)
Diphtheria,
tetanus,
pertussis (DTaP)
No
Dos
1-2 es
Do
3 D ses (In
ose
Pr
NM s (Me ogress
ets
)
Req
ME
uire
m
1-2
Name
No
Dos
es
Dos
es
3D
ose (In Pr
s
(Me ogres
NM
s)
ets
Req
ME
uire
me
nt)
Hepatitis B
)
• 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.
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