Certificate Of Immunization Form - Iowa Department Of Public Health printable pdf download

Iowa Department of Public Health

Certificate of Immunization

Name Last:

First: __________

___

Middle: _____

___________ Date of Birth: _________________

Parent/Guardian: __________________________

Address: _____________________________________________________ Phone: (____)_________________

I certify that the above named applicant has a record of age-appropriate immunizations that meet the requirement for licensed child care or school enrollment.

Signature: __________________________________________________________________ Date: ______________________

Physician, Physician Assistant, Nurse, or Certified Medical Assistant

A representative of the local Board of Health or Iowa Department of Public Health may review this certificate for survey purposes.

Vaccine

Date Given

Doctor / Clinic / Source

Vaccine

Date Given

Doctor / Clinic / Source

Diphtheria,

Meningococca

Tetanus,

MCV4/MPSV4

Pertussis

DTaP/DTP/DT/

Td/Tdap

Hepatitis A

Rotavirus

Polio

IPV/OPV

Human

Papilloma Virus

HPV

Measles,

Mumps,

Rubella

Other

MMR

Haemophilus

influenzae

type b

Hib

Licensed Child Care Requirements

4 through 5 months

19 through 23 months

1 dose Diphtheria/Tetanus/Pertussis

4 doses Diphtheria/Tetanus/Pertussis

1 dose Polio

3 doses Polio

Hepatitis B

1 dose Hib

3 doses Hib with the final dose in the series > 12 months of age, or 1 dose

1 dose Pneumococcal

received > 15 months of age.

1 dose Measles/Rubella > 12 months of age.

6 through 11 months

1 dose Varicella > 12 months of age if born on or after September 15, 1997,

2 doses Diphtheria/Tetanus/Pertussis

or a reliable history of natural disease.

2 doses Polio

4 doses Pneumococcal; or 3 doses if received 1 or 2 doses

2 doses Hib

< 12 months of age; or 2 doses if received 1 dose > 12 months of age

2 doses Pneumococcal

or has not received this vaccine before.

Varicella

12 through 18 months

24 months and older

3 doses Diphtheria/Tetanus/Pertussis

Same requirements as the 19-23 months except 4 doses Pneumococcal

Chicken Pox

2 doses Polio

if received 3 doses < 12 months of age; or 3 doses if received 2 doses

If applicant has a

2 doses Hib or 1 dose received at > 15 months of age.

< 12 months of age; or 2 doses if received 1 dose < 12 months of age

3 doses Pneumococcal if received 1 or 2 doses < 12 months

or received 1 dose between 12 and 23 months of age; or 1 dose if no doses

history of natural

of age; or 2 doses if received 1 dose > 12 months of age

had been received prior to 24 months of age.

disease write

or has not received this vaccine before.

“Immune to

Elementary/Secondary School Requirements

Varicella”

4 years of age and older

5 doses Diphtheria/Tetanus/Pertussis with at least 1 dose received > 4 years of age if born on or after September 15, 2003; or 4 doses, with 1

Pneumococcal

dose received > 4 years of age if born after September 15, 2000, but before September 15, 2003; or 3 doses, with 1 dose received

PCV/PPV

> 4 years of age if born on or before September 15, 2000.

4 doses Polio with 1 dose received > 4 years of age if born on or after September 15, 2003; or 3 doses, with 1 dose received > 4 years of age if born

on or before September 15, 2003.

2 doses Measles/Rubella; the first dose shall have been received > 12 months of age; the second dose shall have been received > 28 days after the first.

3 doses Hepatitis B if born on or after July 1, 1994.

2 doses Varicella > 12 months of age if born on or after September 15, 2003; or 1 dose received > 12 months of age if born on or after September 15,

1997, but before September 15, 2003, unless the applicant has a reliable history of natural disease.

Rev. 12/2008