Nevada Child Care Facility Immunization Rate Reporting Survey

According to NRS 432A.230, each child care facility in Nevada shall report the number of children up to date on their child care vaccines and also include any children conditionally admitted to the facility. This is required on an annual basis before December 31 each year, to be submitted to the NV Division of Public and Behavioral Health.

Please complete the survey below.

Thank you!

First name

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Last name

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Job title

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If other, please specify:

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Phone number

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Email address

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Please write in your Child Care Facility Name - Put the name shown on your Child Care License.

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Please select your child care facility in the drop down list. Please note, the child care facilities are separated by county.

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Child care facility name

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Child care facility's physical address

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City

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Zip Code

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County

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(1) As of September 1st, how many children are enrolled in your child care facility in total?

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(1a) As of September 1st, how many children between 6 and 12 months are enrolled in your child care facility?

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(1b) As of September 1st, how many children between 13 and 17 months are enrolled in your child care facility?

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(1c) As of September 1st, how many children between 18 months and up to 3 years, 11 months of age are enrolled in your child care facility?

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(1d) As of September 1st, how many 4 year old children are enrolled in your child care facility?

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(2) Of the children enrolled from 6 months through 12 months of age, how many received 3 doses of Hepatitis B by 6 months, 30 days old?

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(3) Of the children enrolled from 6 months through 12 months of age, how many received 3 doses of Polio by 6 months, 30 days old?

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(4) Of the children enrolled from 12 months through 17 months of age, how many received 3 or 4 doses of Hib by 12 months, 30 days old?

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(5) Of the children enrolled from 12 months through 17 months of age, how many of them received 4 doses of PCV13 by 12 months, 30 days old?

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(6) Of the children enrolled from 12 months through 17 months of age, how many of them received 1 dose of MMR by 12 months, 30 days old?

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(7) Of the children enrolled from 12 months through 17 months of age, how many of them received 1 dose of Varicella by 12 months, 30 days old?

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(8) Of the children enrolled from 12 months through 17 months of age, how many of them received 1 dose of Hepatitis A by 12 months, 30 days old?

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(9) Of the children enrolled from 15 months through 17 months of age, how many of them received 4 doses of DTaP by 15 months, 30 days old?

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(10) Of the children enrolled from 18 months up to 4 years of age, how many of them received 2 doses of Hepatitis A by 18 months, 30 days old?

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(11) Of the children enrolled from 4 years old up to 5 years of age, how many of them received 5 doses of DTaP by 4 years, 30 days old?

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(12) Of the children enrolled from 4 years old up to 5 years of age, how many of them received 4 doses of Polio by 4 years, 30 days old?

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(13) Of the children enrolled from 4 years old up to 5 years of age, how many of them received 2 doses of MMR by 4 years, 30 days old?

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(14) Of the children enrolled from 4 years old up to 5 years of age, how many of them received 2 doses of Varicella by 4 years, 30 days old?

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(2) Total # UTD for children 1 years of age

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(3) Total # UTD for children 18 months through 3 years of age (3 years and 0 days)

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(4) Total # of UTD children 4 years of age (4 years and 30 days)

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(15) Total # of children medically exempt from any required vaccines

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(15a) Total # of children medically exempt from DTaP (Diphtheria, tetanus, and acellular pertussis)

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(15b) Total # of children medically exempt from Varicella (Chickenpox)

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(15c) Total # of children medically exempt from MMR (Measles, mumps, and rubella)

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(15d) Total # of children medically exempt from IPV (Polio)

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(15e) Total # of children medically exempt from Hepatitis A

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(15f) Total # of children medically exempt from Hepatitis B

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(15g) Total # of children medically exempt from Hib (Haemophilus influenzae type B)

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(15h) Total # of children medically exempt from PCV13 (Pneumoccocal conjugate vaccine)

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(16) Total # of children with religious exemptions from any required vaccines

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(16a) Do all the religious exemptions include all required vaccines? i.e. Each religious exemption form on file is exempt for all required child care vaccines - DTaP/Tdap, Hepatitis A, Hepatitis B, IPV, Hib, MMR, Varicella, and Pneumoccocal (PCV).

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Yes

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(16b) If you selected "no" to the above question, please indicate how many religious exemption forms did not select all vaccines to be exempt from, and state which vaccines the exemption did not apply to.

Example:
4 religious exemption forms didn't have exemptions to all vaccines.
2 - Hib
1 - DTaP
1 - MMR

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(6a) Total # of children religiously exempt from DTaP

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(6b) Total # of children religiously exempt from Varicella

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(6c) Total # of children religiously exempt from MMR

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(17) Total # of children conditionally enrolled between 6 months and up to 4 years, 11 months of age.

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(18) Do you need additional information about vaccines needed for child care entry or anything else pertaining to childhood vaccines? If not, please put "N/A."

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