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Get HI EPI 12A 2006-2024

Ly immunized children. Include children with exemptions to immunizations #1. Facility: Prepared By: Total Enrollment:______ Mailing Address: City, Zip: Title: Phone: Students < 19 mos:_______ Location Address: City, Zip: Date: Fax: Students ≥ 19 mos:_______ #2. All enrollees meet the immunization requirements: #3. Name of Child List only children who are missing required immunizations and children who have an exemption to ANY immunization. Yes BIRTH A ENTRY DATE G DATE (m.

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