Visit Our Other Websites
empty
empty
CORONAVIRUS (COVID-19) RESOURCE CENTER Read More

Increasing Vaccination Record Compliance Among Private Schools

State: FL Type: Promising Practice Year: 2019

Description of LHD: Seminole County is located in East Central Florida just north of Orlando. With an estimated population of 455,479 in 2016 it ranks as the 13th most populous county in Florida, per the U.S. Census Bureau. Seminole County is also the most densely populated county in Central Florida with a total land area of 309.5 square miles and a population density of 1,413.17 per square miles. The racial and ethnic makeup of the county consists of Whites (79.6%), Blacks/African Americans (11.6%), Asians (4%), Native Americans (0.2%), and Native Hawaiian and Other Pacific Islanders (0.1%).  The population identified as Multiple Races comprises 3%. Hispanic origin of any race comprised 18.7% of the population. Languages other than English are spoken in 19% of homes. Families living below poverty level in 2013 ranged from 4% to 13% by zip codes.

The Florida Department of Health in Seminole County (DOH-Seminole) has four service centers located in Sanford (2), Casselberry and through our Mobile Health Unit. DOH-Seminole offers clinical services through the main Sanford location which include family planning, immunizations, STD/HIV prevention and treatment, breast and cervical cancer early detection, men's health screenings, school health screenings and dental care services. A total of 14,638 clients received clinical services during the 2015-16 fiscal year with just over a third (35.6%) being children under the age of 13. Additional services provided by the health department include the Florida Healthy Babies program, Environmental Health, Women Infants and Children (WIC), Vital Statistics, Tobacco Prevention, Refugee Health, Tuberculosis, Epidemiology, Hepatitis, School Health, Public Health Preparedness, Insulin and Epilepsy Medication Distribution.  Supporting departments include Health Promotion and Education, Clinical and Non-Clinical Internships, Quality Improvement and Performance Assessment, Information Technology and Workforce/Employee Wellness.

Additional information regarding DOH-Seminole can be found at our website: http://seminole.floridahealth.gov/index.html

Public Health Issue: Ensuring adequate vaccination coverage among children reduces the risk of vaccine preventable illness.  The state of Florida requires that

prior to entry, attendance or transfer to preschools, schools (K-12), licensed childcare facilities, and family daycare homes, each child shall have on file a Florida Certification of Immunization, DH 680 Form documenting required vaccines. The School Health Program at DOH-Seminole monitors private school immunization compliance rates for KG and 7th grade and provides support to public and private schools with vaccine preventable disease outbreaks. Immunization compliance ensures schools are aware of student population immunization status and, in the case of disease outbreak, they can determine which students may be under or unvaccinated, so they can be removed from campus.  Data from the immunization compliance reports for KG and 7th grades, prior to 2013, showed variation over the years ranging from 4% of the student population being out of compliance to close to 9% in school year 2011-2012. 

This project focused on ensuring private school staff were informed about immunization requirements and had the resources they needed to keep their records up to date, reducing the number of students out of compliance with immunization requirements.

Goals and Objectives: The purpose of this project was to reduce the increasing rate of KG and 7th students in private schools out of compliance with immunizations.

Two of our objectives for this project are:

  • Provide education to administrative or health services staff in all private schools who have KG and 7th grade students regarding immunization requirements, best practices to encourage parents to keep immunizations up to date, and tools to increase compliance with immunization records.
  • By school year 2016-2017, decrease by 3% the number of private students in KG and 7th who are out of compliance with required vaccines (from 8.6% in 2011-2012 to 5.6% in 2016-2017).

Implementation: To address our goals, the School Health team developed a plan which included:

  • Connecting with private school staff to identify needs and knowledge about immunization requirements.
  • Develop an education kit, based on the needs assessment to support private schools in increasing compliance.
  • Provide technical support to schools regarding immunization requirements.

In school year 2012-2013 the DOH-Seminole School Health team assessed factors that were decreasing compliance through site visits to private schools and phone conversations. Some of the challenges identified included high staff turnover rates, limited understanding of immunization guidelines, balancing multiple duties within the school, limited follow up with parents, lack of nurses or staff with health services background and unawareness of compliance tools, goals, among others. The team also noticed several private schools were not reminding parents to bring vaccination records prior to the beginning of the school year.

Based on this information, the school health team created a packet of information for private schools, which included links to the Florida Immunization Guidelines, flyers for parents from the Florida Department of Health Vaccine Immunization bureau with updated vaccine requirements, tips for schools on how to maintain records up to date, and links to helpful on-line resources as well as our team's contact information.  In the spring of 2013-2014 the team began delivering the information packets to the private schools, to help them be better prepared for school year 2014-2015.  This was followed by an e-mail to all private school principals with this same information in the summer.  Finally, the nurses conducted site visits and provide technical support at the beginning of the school year between the months of August -October to help the schools review immunization records and answer questions. In the spring of 2014-2015, a newsletter was e-mailed to all private schools recognizing all the schools who achieved 100% compliance by the deadline and provided tips to help encourage compliance.  The team continues to monitor compliance rates every year and provides the immunization education kit and technical support to private schools as needed. 

Results/Outcomes: Since implementation of immunization education and support strategies in 2013-2014, every school year private schools with KG and 7th grade students have received the immunization information packet.  Since our team implemented the practice, the rate of non-compliant KG and 7th grade students decreased from 8.6% in 2011-2012 to 2.6%. Furthermore, this practice has increased awareness of vaccination requirements and importance among private school staff, strengthen public health relationship with private schools, increase support for vaccination coverage and increased readiness of private schools in case of outbreaks.  It also reduced the time spent by public health school nurses following-up with private schools and tracking immunization records by 50%, leading to an estimated annual cost savings of $5,124.

Public Health Impact of Practice:  This project impacts the following essential public health services:


  • Inform, educate and empower people about health issues- By creating immunization education kits for private school staff and providing technical support and assistance in reviewing the student immunizations our team raised awareness about the immunization requirements and about the importance of keeping compliance with record keeping.
  • Mobilize community partnerships and action to identify problems- This project helped our team build stronger partnership bridges with our private schools.  Collaborating with private school staff was crucial to the success of this initiative, form conducting the initial assessment to identifying needs and best practices that could be shared with other private schools.
  • Enforce laws and regulations that protect health and ensure safety- This project increased KG and 7th grade student immunization compliance rates from 91.4% in 2011-2012 to 97.4% 2017-2018.

Target population

According to the Florida Department of Education, in school year 2017-218 a total 9,699 students attended private school in Seminole County. Of these, 773 students were reported to attend Kindergarten and 730 attended 7th grade. Florida Statutes require public and private educational institutions to follow state immunization requirements, which include appropriate doses of diphtheria, tetanus, pertussis, hepatitis B, polio, measles, mumps, rubella and varicella for youth enrolling in KG and attending 7th grade.

Recent outbreaks of measles and mumps have shined the spotlight on the reemergence of vaccine preventable diseases. The incidence of vaccine reportable disease in 2017, Seminole County reported 2 cases of mumps out of 74 total cases reported in the state of Florida. In the same year, Seminole county reported 24 cases of varicella (up from 11 on 2016) out of a total of 656 cases reported throughout the state.  Furthermore 43 cases of pertussis were reported in Seminole County between 2014 and 2017.  Ensuring adequate levels of vaccination in a population is one of public health's greatest disease prevention success stories, and policies that support and enforce vaccination requirements have proven to be instrumental to this success.


Non-compliance of private school student with vaccine requirements raised several public health concerns:

  • Historically, in Seminole county, the percentage of private school KG and 7th grade students with documented doses of required vaccines has historically trended lower than the percent for public schools. This means that there is a larger population of students in private schools who are not adequately protected against vaccine preventable diseases.  For example, for 2017-2018 school year, the percent of KG grade students with certified immunization records in public schools was 91%, whereas for private schools it was 89.5%.  For the same school year, the percent of 7th grade students with certified immunization records in public schools was 97%, whereas for private schools it was 94.5%.  Several factors influence this percentage, including temporary exemptions, medical exemptions, religious exemptions and non-compliance with documentation.  Furthermore, Seminole county public schools, do not allow students to start classes unless they present required vaccination records at the start of the school year. Although some private schools have put this measure in practice, others are more lenient.
  • The number of students with religious exemptions in Seminole County private schools has also been increasing over the years from 3.4% in school year 2010-2011 to 12% in school year 2017-2018.   In comparison, the percentage of students in public schools with religious exemptions for school year 2017-2018 was 5.3%.  Both factors combined increase the percentage of student who may be susceptible to vaccine preventable diseases in private schools.
  • Ability of private schools to adequately respond to a vaccine preventable disease outbreak may be dependent on the student population size, having health trained personnel and understanding disease prevention and immunization requirements and practices. Through the initial assessment conducted with private school staff for this project, we discovered different levels of understanding of immunization practices, school responsibilities and public health response.

Through this project, the school health team was able to establish stronger relationships with all private schools in the Seminole county area which serve KG and 7th grade students, and provide education regarding immunization requirement, tips to keep vaccine records up to date and share best practices from other private schools.     Since our team implemented the practice, the rate of non-compliant KG and 7th grade students decreased from 8.6% in 2011-2012 to 2.6%. Furthermore, this practice has increased awareness of vaccination requirements and importance among private school staff, strengthen public health relationship with private schools, increase support for vaccination coverage and increased readiness of private schools in case of outbreaks. 


Innovation and use of Evidence Based Guidelines: The state of Florida requires private schools to self-report compliance with immunization records.  In addition to ensuring compliance with this reporting, the school health program provided an open line of communication between the private schools in and our health department, by visiting the schools, delivering the immunization information kit, educating staff about immunization requirement and providing technical support to private schools who have questions.

This intervention supports recommended best practices summarized in the Vaccine Recommendation and Guidelines of the Advisory Committee on Immunization Practices (ACIP), which outlines that one of the recommended ways to increase community demand of vaccine is by ensuring vaccines are required for entry to schools, child-care facilities and colleges. By ensuring school staff has the tools to understand and enforce vaccine requirements and by providing technical support, the school health team has helped to empower private school personnel to ensure vaccine requirements are met by students entering to schools.

This project focused on ensuring private school staff were informed about immunization requirements and had the resources they needed to keep their records up to date, reducing the number of students out of compliance with immunization requirements.

Goals and Objectives: The purpose of this project was to reduce the increasing rate of KG and 7th students in private schools out of compliance with immunizations.

Two of our objectives for this project are:

  • Provide education to administrative or health services staff in all private schools who have KG and 7th grade students regarding immunization requirements, best practices to encourage parents to keep immunizations up to date, and tools to increase compliance with immunization records.
  • By school year 2016-2017, decrease by 3% the number of private students in KG and 7th who are out of compliance with required vaccines (from 8.6% in 2011-2012 to 5.6% in 2016-2017).

Implementation: To address our goals, the School Health team developed a plan which included:

  • Connecting with private school staff to identify needs and knowledge about immunization requirements.
  • Develop an education kit, based on the needs assessment to support private schools in increasing compliance.
  • Provide technical support to schools regarding immunization requirements.

In school year 2012-2013 the DOH-Seminole School Health team assessed factors that were decreasing compliance through site visits to private schools and phone conversations. Some of the challenges identified included high staff turnover rates, limited understanding of immunization guidelines, balancing multiple duties within the school, limited follow up with parents, lack of nurses or staff with health services background and unawareness of compliance tools, goals, among others. The team also noticed several private schools were not reminding parents to bring vaccination records prior to the beginning of the school year.

Based on this information, the school health team created a packet of information for private schools, which included links to the Florida Immunization Guidelines, flyers for parents from the Florida Department of Health Vaccine Immunization bureau with updated vaccine requirements, tips for schools on how to maintain records up to date, and links to helpful on-line resources as well as our team's contact information.  In the spring of 2013-2014 the team began delivering the information packets to the private schools, to help them be better prepared for school year 2014-2015.  This was followed by an e-mail to all private school principals with this same information in the summer.  Finally, the nurses conducted site visits and provide technical support at the beginning of the school year between the months of August -October to help the schools review immunization records and answer questions. In the spring of 2014-2015, a newsletter was e-mailed to all private schools recognizing all the schools who achieved 100% compliance by the deadline and provided tips to help encourage compliance.  The team continues to monitor compliance rates every year and provides the immunization education kit and technical support to private schools as needed. 

Results/Outcomes: Since implementation of immunization education and support strategies in 2013-2014, every school year private schools with KG and 7th grade students have received the immunization information packet.  Since our team implemented the practice, the rate of non-compliant KG and 7th grade students decreased from 8.6% in 2011-2012 to 2.6%. Furthermore, this practice has increased awareness of vaccination requirements and importance among private school staff, strengthen public health relationship with private schools, increase support for vaccination coverage and increased readiness of private schools in case of outbreaks.  It also reduced the time spent by public health school nurses following-up with private schools and tracking immunization records by 50%, leading to an estimated annual cost savings of $5,124. 

This project helped our team build stronger partnership bridges with our private schools.  Collaborating with private school staff was crucial to the success of this initiative, form conducting the initial assessment to identifying needs and best practices that could be shared with other private schools. 

Cost and Savings Associated with practice:

Estimated Time spent by nurses and cost of following-up with private schools that were out of compliance prior to improvement:
Visit to 40 schools: 100hrs X $35 X 2.4 nurses= $8,400
Follow up with schools with multiple non-compliant student records = 2hr/wk X 4wks X $35 X 2.4 nurses= $672
Total: $9,072
Time spent by nurses and cost following-up with private schools that are out of compliance after improvement:
Visit to 30 schools (some schools self-report now): 45hrs X $35 X 2.4 nurses= $ 3,780
Follow-up with schools with multiple non-compliant student records= .5hr/wk X4wks X X$35X 2.4= $168
Total: $3,948
Savings: $5,124 (over 50% cost reduction)
Other benefits to state:

  • Increase accuracy of immunizations records
  • Decrease risk of vaccine preventable disease outbreak
Data utilized for this project is collected through the annual Private School Immunization Compliance report conducted by the Florida Department of Health School Health Program. These and other state immunization reports may be found at:http://www.floridahealth.gov/statistics-and-data/immunization-coverage-surveys-reports/state-surveys.html.   
Following implementation of this practice, the percent of schools not compliant with documentation for 7th grade students decreased from 5.5% in school year 2011-2012 to 1.2% in 2017-2018. The total % non- compliant student records for 7th grade and KG for this same time period has also dropped from 8.6% to 2.9%.  In addition, the nurses now spend over 50% less time following up with non-compliant schools.  We believe this practice has increased awareness of vaccination requirements and importance among private school staff, strengthen public health relationship with private schools, increase support for vaccination coverage and increased readiness of private schools in case of outbreaks.  It also reduced the time spent by public health school nurses following-up with private schools and tracking immunization records by 50%, leading to an estimated cost annual cost savings of $5,124.

The DOH-Seminole School Health team designed kit for private schools with tools with tips, flyers, best practices from other private schools and a newsletter as a way to help educate and help private school personnel gain access to immunization requirements information. In addition, the team has continued to foster good relationships with private schools, so they know we are available to answer questions and provide technical support when needed.  Having nurses available to answer question and provide education about immunizations has been invaluable to our program and has been especially helpful in ensuring the accuracy of the data/records review as well as gaining the trust of private schools who may not have trained health personnel to review records.  Although these may not be original tools, this practice supports CDC's ACIP recommendations and the strategy of providing immunizationeducation to private schools and building collaboration bridges to increase immunization compliance, has been innovative in our county and has produced the desired outcomes.  Although these resources may not be available in other counties due to the high number of schools and the limited nursing staff, providing this education and technical support to private schools has been a return on investment, creating a platform for a sustainable practice, since it not only improved compliance with documentation, but has strengthen our relationship with the schools, and has represented a times saving for our nurses.

I am a previous Model Practices applicant