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ARIZONA DEPARTMENT OF HEALTH SERVICES
Health and Wellness for All Arizonans
ARIZONA DEPARTMENT
OF HEALTH SERVICES
Immunization Data Report
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SCHOOL PROFILE:
×
PRINCIPAL/DIRECTOR
First Name
Last Name
Email
Phone
Ext
PRIMARY IDR CONTACT
First Name
Last Name
Email
Phone
Title
District Nurse
School Nurse
Other
SCHOOL DETAILS:
Does this school have a Nurse?
Nurse Type
Yes
No
RN
LPN
Both
Who is responsible for student health records?
District Nurse
Front Desk
Health Aid
Other
Other Health Staff
Principal
How many nurses are at your school?
1
2
3
4+
Who is filling out the IDR?
District Nurse
Front Desk
Health Aid
Other
Other Health Staff
Principal
CTDS/License
School Type
Physical Address
Mailing Address
ADDITIONAL INFORMATION
Does your preschool run a private kindergarten or 6th grade that is not affiliated with a public school district?
Yes
No
Please select your private K or 6 school:
--Select--
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
-- Select School --
OR
My grade school is not listed. Information will be automatically added below.
PRINCIPAL/DIRECTOR: Private K or 6
First Name
Last Name
Email
Phone
Ext
PRIMARY IDR CONTACT
First Name
Last Name
Email
Phone
Title
District Nurse
School Nurse
Other
SCHOOL DETAILS: Private K or 6
Does this school have a Nurse?
Nurse Type
Yes
No
RN
LPN
Both
Who is responsible for student health records?
District Nurse
Front Desk
Health Aid
Other
Other Health Staff
Principal
How many nurses are at your school?
1
2
3
4+
Who is filling out the IDR?
District Nurse
Front Desk
Health Aid
Other
Other Health Staff
Principal
CTDS/License
School Type
Physical Address
Mailing Address
IF SCHOOL INFORMATION (CTDS/LICENSE, SCHOOL TYPE, PHYSICAL ADDRESS, MAILING ADDRESS) IS INCORRECT, PLEASE CONTACT AZIDR@AZDHS.GOV
USER REGISTRATION
NOTE: If you are having difficulty registering or logging in, please email
AZIDR@azdhs.gov
for assistance.
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Password:
First Name:
Last Name:
Phone:
Ext:
Role
--Select--
Staff
Nurse
Principal
Director
Select the School(s) you will be reporting for:
School Type:
--Select--
Child care/Preschool
Grade School
County:
--Select--
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
School:
-- Select School --
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