896 Immunization Certificate Form
This will generate a PDF of the Maryland 896 Immunization Certificate Form.
Selection Criteria
The student has an Enroll Status of 0.
Or the student is selected using the Current Selection Students parameter below.
Required Set-up:
Use the Immunizations setup to populate the State Report Name and Code fields on the Vaccines, Exemption Types, and Certificate Types screens (Start Page > District > Health Setup > Immunizations).
Enter student vaccine information on the student Immunization screen (Start Page > select a student > Health > Immunizations).
If setting the Report Medical Exemption Comment parameter below to Yes, then only use the student vaccine Comment field for the exemption explanation. This Comment field is found by clicking on the Vaccine name when on the student Immunization screen.
Identify source of Parent or Guardian name. (Start Page > District > Student Contact Adoption Status). If setting this option to No then additional setup is required using Start Page > District > Online IEP setup.
Report Input
For help with navigation and running the report, see How to Find and Generate a Report.
Field | Description |
|---|---|
Report Parameters | Set Select All; this will store your selections for this report which is helpful when you need to submit a new file and you are unsure of how you created your last file. |
Select Schools* | If run at the district level, choose one of the following:
If run at the school level, the report includes all records associated with the current school that meet the selection criteria. To change the current school, click School at the top of the page and choose the appropriate school from the list. |
Current Selection Students* | Indicate which students to include in the report by selecting one of the following options:
Note: If running the report for a single student, or group of students, select the students prior to running report. |
Report Medical Exemption Comment | Select No or Yes to include Medical Exemption Comment in the report output. |
Scheduling | Click Run Now to run this report immediately, or click Schedule to schedule it to run later. |
Report Output
Each of the fields displayed in the output of the report are described below. See Understanding the Report Output Table for a definition of each column in the table.
Data Element | Description | [Table]FieldName |
|---|---|---|
Child's Name | The students last name, first name, middle name. | [Students]Last_Name [Students]First_Name [Students]Middle_Name |
Sex | The student's gender. | [Students]Gender |
Birthdate | The birth date of the student. | [Students]DOB |
County | The name of the County. | [S_MD_STU_X]county_code or [PREFS]districtnumber |
School | The school name. | [Schools]Name |
Grade | The grade level of the student. | [Students]Grade_Level |
Parent or Guardian Name | Name of student's parent or guardian. If a District is using Student Contacts this information is the Contact with the Custody flag checked and Order of 1. | [Prefs] MD_p1_first_name [Person]FirstName [Prefs] MD_p1_last_name [Person]LastName |
Parent or Guardian Phone No. | This is the student's home phone number and comes from the Demographics page. | [Students]Home_Phone |
Parent or Guardian Address | This is the student's address and comes from the Demographics page. | [Schools]Address |
Parent or Guardian City | This is the student's city and comes from the Demographics page. | [Students]City |
Parent or Guardian Zip | This is the student's zip code and comes from the Demographics page. | [Students]Zip |
Record of Immunization | ||
DTaP/DTP/Tdap/DT/Td | Vaccination dates for Diphtheria/Tetanus/Pertussis (DTaP/DTP/Tdap/DT/Td) | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode=tdap |
Polio | Vaccination dates for Polio. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Hib | Vaccination dates for Hib. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Hepatitis B | Vaccination dates for Hepatitis B. | [[HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
PCV | Vaccination dates for PCV. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Rotavirus | Vaccination dates for Rotavirus. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Meningococcal (MCV4) | Vaccination dates for Meningococcal (MCV4). | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
HPV | Vaccination dates for HPV. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Hepatitis A | Vaccination dates for Hepatitis A. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Measles, Mumps, Rubella | Vaccination dates for Measles, Mumps, Rubella. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Varicella (Chickenpox) | Vaccination dates for Varicella (Chickenpox). | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
Tdap booster | Vaccination dates for Tdap booster. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
FLU | Vaccination dates for FLU. | [HealthStudDoseRec]DateAdministered Where [HealthVaccine]StateReportCode= |
School Information | ||
School Name | Name of the school. | [Schools]Name |
School Address | Address of the school. | [Schools]Name [Schools]SchoolAddress [Schools]SchoolCity [Schools]SchoolState [Schools]SchoolZip |
School Phone Number | Phone number of the school. | [Schools]SchoolPhone |
Medical Contraindications | ||
Medical - Permanent | Student is exempt due to a medical contraindication permanent. | Where [HealthImmExempt]StateReportCode=med_perm |
Medical - Temporary | Student is exempt due to a medical contraindication temporary. | Where [HealthImmExempt]StateReportCode=med_temp [HealthStudImmRec]ExemptionExpiryDate |
Religious Objection | ||
Religious Objection | Student is exempt due to a religious objection. Note: Religious Objection does not print on the PDF. | Where [HealthImmExempt]StateReportCode=religious |
History of Varicella Disease | ||
History of Varicella (Chickenpox) | Student is exempt due to history of Varicella disease. Note: Prints the Mo/Yr of the disease on the PDF. | Where [HealthImmExempt]StateReportCode=varicella_disease |