Immunization Record Card (ASIR109R)

Field

Description

Select Schools

Choose one of the following:

• Current School Only – Includes all student records associated with the current school that meet selection criteria. To change the current school, click the School link at the top of the page and choose the appropriate school from the list.

• All Schools – Includes all student records on the PowerSchool server that meet selection criteria.

Note: The All Schools option is only available when running the report from the District Office.

Current Selection Students

Indicate which students to include in the report by selecting one of the following options:

• The selected [number] students only – Run the report for students in the current selection.

• All students – Run the report for all students in the current school or district that meet the selection criteria.

Note: If running the report for a single student, or group of students, select the students prior to running report.

Contact Person

Enter the name of the contact staff member.

Phone Number

Enter the contact's phone number,

Print Instruction Page?

Choose Yes or No from the pop up menu to indicate whether or not to print the state instructions page.

Data Element

Description

[Table]FieldName

I. IDENTIFICATION INFORMATION

Child's Name

The student's name.

[Students]Last_Name

[Students]First_Name

[Students]Middle_Name

Birth Date

The student's date of birth.

[Students]DOB

Entry Grade

The student's grade level during the reported school year.

[Students]SchoolEntryGradeLevel

Sex

The student's gender.

[Students]Gender

II. IMMUNIZATIONS

(DTaP/DTP) Diphtheria, Tetanus & Pertussis

The dates of the student's six most recent DTaP/DTP vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = DTaP_DTP

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(Td) Tetanus & Diphtheria

The dates of the student's six most recent TD vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = TD

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(Tdap) Tetanus, Diphtheria, acellular Pertussis

The dates of the student's six most recent TDAP vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = Tdap

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(IPV/OPV) Polio Vaccine

The dates of the student's six most recent IPV/OPV vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = IPV_OPV

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(MMR) Measles, Mumps & Rubella

The dates of the student's six most recent MMR vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = MMR

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(Hep B) Hepatitis B

The dates of the student's six most recent hepatitis B vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = HepB

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

Varicella (Chickenpox)

The dates of the student's six most recent varicella vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = VAR

[HealthImmExempt]StateReportCode = Hist_Recall

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

Meningococcal

The dates of the student's six most recent meningococcal vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = MV_MCV

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(Hep A) Hepatitis A

The dates of the student's six most recent hepatitis A vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = HepA

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

HPV (Human Papilloma Virus)

The dates of the student's six most recent HPV vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = HPV

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

(Hib) Haemophilus Influenzae b

The dates of the student's six most recent HIB vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = Hib

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

Influenza (Flu) Vaccine

The dates of the student's six most recent flu vaccinations from 1st vaccination to 6th vaccination.

Note: The value for F/U Date is not provided by PowerSchool.

[HealthStudImmRec]HealthVaccineID = Flu

[HealthStudDoseRec]Dose

[HealthStudDoseRec]DateAdministered

Other

The dates of the student's six most recent school-specified vaccinations from 1st vaccination to 6th vaccination.

Note: This field is not provided by PowerSchool.

N/A

TB Skin Test (Optional)

The dates of the student's six most recent TB skin tests from 1st test to 6th test.

Note: This field is not provided by PowerSchool.

N/A

FOR SCHOOL USE ONLY

School Name

The name of the school.

[Schools]Name

Contact Person

The name of the contact staff member.

N/A

Phone Number

The staff contact's phone number.

N/A

Initial Enrollment Date in an Arizona School/Preschool

The date the student was first enrolled in an Arizona school.

[S_AZ_STU_X]FirstAZSchooling

III. Documentation Presented

Note: This section is not provided by PowerSchool.

Arizona Lifetime Record

Select the checkbox if the Arizona Lifetime Record is used to transcribe information onto this report.

N/A

Foreign country (name)

Select the checkbox and enter the record name of the if a record from a foreign country is used to transcribe information onto this report.

N/A

Out-of-State record (name)

Select the checkbox and enter the name of the record if an out-of-state record is used to transcribe information onto this report.

N/A

ASIIS

Select the checkbox if the AIIIS record is used to transcribe information onto this report.

N/A

Provider Record

Select the checkbox if the Provider Record is used to transcribe information onto this report.

N/A

Other

Select the checkbox and enter the name if another record is used to transcribe information onto this report.

N/A

IV. Status of Requirements

Note: This section is not provided by PowerSchool.

A. Currently up-to-date; more doses are due later.

Select the checkbox if the student's vaccinations are currently up to date and more doses are due later.

N/A

B. Needs follow-up (see follow-up column).

Select the checkbox if the student needs a follow-up vaccination.

N/A

C. No immunization record provided.

Select the checkbox if no immunization record is provided and enter the reason none is provided.

N/A

D. Medical Exemption—Permanent

Select the checkbox if the student has a permanent medical exemption and enter the date applicable.

N/A

E. Laboratory evidence of immunity attached:

Select the checkbox if the student has a verified immunity against the infirmity and enter the title of documentation.

N/A

F. Medical Exemption—Temporary until

Select the checkbox if the student has a temporary medical exemption and enter the date the exemption expires.

N/A

G. Personal Beliefs

Select the checkbox if the student has not been vaccinated for personal reasons and enter the date the exemption expires.

N/A

Date

Enter the date of certification

N/A

Admitting Official

Enter signature.

N/A

Comment Section

Enter any comments.

N/A