Form Ip-100/101 - Reporting Form For School/childcare Immunization Reporting
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1Michigan Department of Health and Human Services
IP-100/101 Reporting Form for School/Childcare Immunization Reporting
Instructions: Please provide this form to schools or childcares to complete for manual reporting or for children whose records are
not stored in MCIR.
It will be necessary for the Local Health Department to assess this record, return it to the school or childcare center for follow-up if
additional immunizations are needed, and then edit
the MCIR/SIRS data after the report period is closed, using this additional information.
Report Period:
February ____
November ____
October ____
School/Childcare Name__________________________________________________________________
Child’s Name_________________________________________________ Date of Birth_______________
□
□
Vision Screening for Kindergarten Only*
Yes
No
DTP/DTaP/
DTP/DTaP/
DTP/DTaP/
DTP/DTaP/
DTP/DTaP/
DTP/DTaP/
*Series
Tdap/Td 1
Tdap/Td 2
Tdap/Td 3
Tdap/Td 4
Tdap/Td 5
Tdap/Td 6
Waived
*Series
POLIO 1
POLIO 2
POLIO 3
POLIO 4
POLIO 5
Waived
*Series
MMR 1
MMR 2
MMR 3
Waived
*Series
HEP-B 1
HEP-B 2
HEP-B 3
HEP-B 4
Waived
*Series
HIB 1
HIB 2
HIB 3
HIB 4
Waived
*Series
VAR 1
VAR 2
VAR 3
Had Disease
Waived
*Series
PCV 1
PCV 2
PCV 3
PCV 4
PCV 5
Waived
Meningococcal
Meningococcal
MenACWY
MenACWY
*Series
(MCV4)
(MCV4)
Waived
1
2
*Please mark R=Religious, M=Medical, or O=Other in the Series Waived box, Attach waiver to this form.
****************************************************************************************************************************
For Local Health Department Use Only
Date Assessed___________________
hild’s Status (Complete, Provisional, Incomplete, Waiver): ______________
C
If incomplete or provisional, record reason:______________________________________________
Rev. June 6, 2017
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