Certificate Of Immunization Exemption Form - Iowa Department Of Public Health

Iowa Department of Public Health

Certificate of Immunization Exemption

Medical

Name Last: ___________________________

First: _________________________

Middle: _______________

Date of Birth: ___________________

The above named applicant qualifies for a Medical Exemption to Immunization for the following reason (select one):

In the opinion of a physician, nurse practitioner, or physician assistant the required immunizations would be injurious to the health and well-being of the applicant or any

member of the applicant’s family or household. In this circumstance, the exemption may apply to a specific vaccine(s) or all vaccines. If, in the opinion of the physician,

nurse practitioner, or physician assistant issuing the medical exemption, the exemption should be terminated or reviewed at a future date, an expiration date shall be

recorded on the Certificate of Immunization Exemption.

Administration of the required vaccine would violate minimum interval spacing. In this circumstance, the exemption shall apply only to an applicant who has not received

prior doses of exempted vaccine. An expiration date, not to exceed 60 days, and the name of the vaccine shall be recorded on the certificate.

Medical exemptions do not apply in times of emergency or epidemic as determined by the state board of health and declared by the director of public health.

A Certificate of Immunization Exemption for medical reasons is valid only when signed by a physician, nurse practitioner, or physician assistant.

List vaccine(s): ____________________________________________________

Certificate Expiration Date: __________________

Signature: ________________________________________________________

Date: ____________________________________

Physician (MD or DO), Physician Assistant, Nurse Practitioner

Religious

Name Last: ___________________________

First: _________________________

Middle: _______________

Date of Birth: ___________________

A religious exemption may be granted to an applicant if immunization conflicts with a genuine and sincere religious belief. A Certificate of Immunization Exemption for religious

reasons shall be signed by the applicant or, if the applicant is a minor, by the parent or guardian or legally authorized representative and shall attest that the immunization conflicts

with a genuine and sincere religious belief and that the belief is in fact religious, and not based merely on philosophical, scientific, moral, personal, or medical opposition to

immunizations. The Certificate of Immunization Exemption for religious reasons is valid only when notarized. Religious exemptions do not apply in times of emergency or epidemic

as determined by the state board of health and declared by the director of public health.

Signature:

Date:

Applicant, Parent or Guardian

State of _______________________

County of ________________________

Seal or Stamp

This instrument was acknowledged before me on ___________________________

Date

by __________________________________________________________________

Name(s) of Person(s)

Signature of Notary Public: ______________________________________________

Title (or Rank for Military Personnel): _____________________________

Rev. December 2008