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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.



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:

  • Select Multiple Schools – Select schools to include in the report. To select a single school, click that school. To select multiple schools, use Ctrl+Click and select each school to be included. Select schools to include in the report

  • All Schools – Run the report for the entire district.

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:

  • The Selected [number] Students Only

  • All Students

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.


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



Child's Name

The students last name, first name, middle name.





The student's gender.



The birth date of the student.



The name of the County.

[S_MD_STU_X]county_code or



The school name.



The grade level of the student.


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


[Prefs] MD_p1_last_name


Parent or Guardian Phone No.

This is the student's home phone number and comes from the Demographics page.


Parent or Guardian Address

This is the student's address and comes from the Demographics page.


Parent or Guardian City

This is the student's city and comes from the Demographics page.


Parent or Guardian Zip

This is the student's zip code and comes from the Demographics page.


Record of Immunization


Vaccination dates for Diphtheria/Tetanus/Pertussis (DTaP/DTP/Tdap/DT/Td)





Vaccination dates for Polio.





Vaccination dates for Hib.




Hepatitis B

Vaccination dates for Hepatitis B.





Vaccination dates for PCV.





Vaccination dates for Rotavirus.




Meningococcal (MCV4)

Vaccination dates for Meningococcal (MCV4).





Vaccination dates for HPV.




Hepatitis A

Vaccination dates for Hepatitis A.




Measles, Mumps, Rubella

Vaccination dates for Measles, Mumps, Rubella.




Varicella (Chickenpox)

Vaccination dates for Varicella (Chickenpox).




Tdap booster

Vaccination dates for Tdap booster.





Vaccination dates for FLU.




School Information

School Name

Name of the school.


School Address

Address of the school.






School Phone Number

Phone number of the school.


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


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

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