Certificate Of Immunization - Georgia Department Of Public Health
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1Rev. 03/2014
Georgia Department of Public Health
3231
Form
Interim
CERTIFICATE OF IMMUNIZATION
(Fill in X)
OR
Child's Name (Last name first)
Date of Expiration
Complete For School Attendance
Birthdate
Child must be ≥ 4 years and have met all
(Next required immunization
requirements for school attendance. The
or review of medical
vaccine history section must be filled in.
exemption due.)
(Optional) Parent/Guardian Name (Last name first)
Unless specifically exempted by law, Georgia law (O.C.G.A. § 20-2-771) requires a certificate on file for each child in attendance in any school or child care
facility in Georgia with penalties for failure to comply. Detailed instructions for this form and immunization requirements by age are spelled out in policy guides
3231INS and 3231REQ distributed by the Georgia Immunization Office.
VACCINE
DATE
DATE
DATE
DATE
DATE
DATE
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
Required Vaccines for School or Child Care Attendance
DTP, DTaP, DT, Td
Polio
Hepatitis B
Tdap
MCV4
HIB
(Under Age 5)
PCV
(Under Age 5)
Measles
Mumps
Rubella
Hepatitis A
(Born on/after 1/1/06)
Varicella
Recommended Vaccines (For Information Only)
Rotavirus
HPV (3 Doses)
Influenza
Td Booster
Notes:
Printed, Typed or
A licensed Georgia physician, Advanced Practice Registered Nurse, Physician
Stamped Name,
Assistant, qualified employee of a local Board of Health or the State Immunization Office is
responsible for the content and certification of this certificate with legible name, address,
Address and
signature and date of issue. All dates must include month, day and year. In cases of natural
Telephone # of
immunity or Medical Exemption, the 4 digit year of infection, test or exemption must be filled
in the appropriate box(es). The certificate is NOT valid without name and birthdate of
Licensed
the child, date of expiration OR “X” in Complete for School Attendance box. A school
Physician
or facility official is responsible for keeping a current valid certificate on file for each child in
or Health Department
attendance. A certificate must be replaced within 30 days after expiration. When a child
leaves or transfers to another facility, the Certificate of Immunization should be
given to a parent/guardian or sent to the new facility.
Certified by (Signature/Signature Stamp)
Date of Issue
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