DEPARTMENT OF HEALTH SERVICES Division of Public Health F04002 (Rev. 07/2021)STATE OF WISCONSIN Wis. Stat. 252.04 Page 1 of 5SCHOOL REPORT TO LOCAL HEALTH DEPARTMENT, 20212022 Wisconsin Stat. 252.04.

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How to fill out the WI DHS F-04002 online

The WI DHS F-04002 form is essential for schools in Wisconsin to report student immunization compliance to local health departments. This guide will provide clear and supportive instructions on how to complete the form online.

Follow the steps to accurately fill out the form.

  1. Click the ‘Get Form’ button to obtain the form and open it for completion.
  2. In Section A, fill out the school’s information, including the Local Education Agency (LEA) code and the DPI School Code. Ensure you accurately report the grades enrolled at the school.
  3. In Section B, categorize the number of students based on immunization compliance for each vaccine. Use the specific categories (e.g., meets minimum requirements, in process) for accurate reporting. Remember to enter zeros where applicable.
  4. Section C requires you to report the total number of students meeting specific criteria such as those with waivers or those with no immunizations. Ensure that the sums are accurate and align with your data.
  5. In Section D, list the number of students who have specific types of waivers, ensuring that each metric is clear and accurate.
  6. After completing all sections, review the form for accuracy. Make any necessary corrections and ensure all data is complete before submitting.
  7. Finally, you can save changes, download, print, or share the form as needed.

Complete your forms online today to ensure timely compliance with health reporting requirements.

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Is it illegal to not vaccinate your child in Wisconsin?

Failure to meet Wisconsin's immunization requirements is AGAINST THE LAW. If you fail to comply with the law, you may be fined up to $25 per day, and your child may be excluded from child care or school.

Click on the 'Public Immunization Record Access' hyperlink from the login screen for the Wisconsin Immunization Registry web site. The Public Access Search screen displays. Enter the first name, last name, and date of birth for the person whose record you are searching for. These are required fields.

Choosing to opt-out of participation in the WIR, for yourself, or your child, means that the demographic and immunization information is locked so it is not available to any WIR users or to the individual themselves.

Waiver: Waivers are available for medical/health, religious, or personal conviction reasons. Children for whom waivers are filed are compliant.

Students should receive the Tdap (tetanus, diphtheria and acellular pertussis) vaccine before the start of 7th grade rather than 6th grade. Students who received one dose of Tdap prior to the start of 6th grade under the previous requirement are compliant and do not need to receive an additional dose of Tdap.

Parents who choose to waive an immunization are required to sign a waiver on the Student Immunization Record form, F-04020L, and list the dates (month, day, year) of all of the vaccines the child has already received.

To protect students and children from diseases that are preventable by immunization, Wisconsin law requires all students to show that they have received the required immunizations or have a signed waiver.

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