Worksheet for Children 7 through 15 Months
(Birth dates June 2, 2015 - March 1, 2016)
Number in column
Dos
es
ose
NM (Meet
s Re
qui
ME
rem
ent
)
Haemophilus
influenzae
type b (Hib)
1D
No
2D
No
Dos
1-2 es
Do
3 D ses (In
ose
s (M Progr
es
NM
eet
s Re s)
qui
ME
rem
me
nt)
(In
ose Progr
es
s (M
NM
eet s)
s Re
qui
ME
re
es
ose
Dos
1D
Pneumococcal
conjugate vaccine
(PCV)
ent
)
Polio
(IPV or OPV)
ent
)
No
Name
Diphtheria,
tetanus,
pertussis (DTaP)
No
Dos
1-2 es
Dos
es
3D
ose (In Pro
s (M
g
NM
eet ress)
s Re
qui
ME
rem
es
Dos
es
3D
ose (In Pr
og
s (M
NM
eet ress)
s Re
qui
ME
re
me
nt)
Hepatitis B
Dos
•
1-2
•
•
No
•
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.
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