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:   	
Physician, Physician Assistant, Nurse, or Certified Medical Assistant

Date:   	

	Vaccine	Date Given	Doctor / Clinic / Source	
Diphtheria, Tetanus, Pertussis DTaP/DTP/DT/ Td/Tdap				

				

				

				

				

Polio
IPV/OPV				

				

	
Measles, Mumps, Rubella MMR				

				
	
Haemophilus influenzae type b
Hib				

				

Hepatitis B				

				

				

	Vaccine	Date Given	Doctor / Clinic / Source	
Varicella				
Chicken Pox				
				
If patient has a history				
				
of natural disease				
write “Immune to				
				
Varicella”				

Pneumococcal
PCV/PPV				

				

	
Meningococcal
MCV4/MPSV4				

				
	
Hepatitis A				

				

Rotavirus				

				

	
Human				
Papilloma				
				
Virus				
				
HPV				

Other				

				

A representative of the local Board of Health or Iowa Department of Public Health may review this certificate for survey purposes.
January 2013

IMMUNIZATION REQUIREMENTS
Applicants enrolled or attempting to enroll shall have received the following vaccines in accordance with the doses and age requirements listed below. If, at any time, the age of the child is between the listed ages, the child must have received the number of doses in the “Total Doses Required” column.
Institution	Age	Vaccine	Total Doses Required	
Licensed Child Care Center	Less than 4
months of age	This is not a recommended administration schedule, but contains the minimum requirements for participation in licensed child care. Routine vaccination
begins at 2 months of age.	
	4 months
through 5 months of age	Diphtheria/Tetanus/Pertussis	1 dose	
		Polio	1 dose	
		haemophilus influenzae type B	1 dose	
		Pneumococcal	1 dose	
	6 months
through 11 months of age	Diphtheria/Tetanus/Pertussis	2 doses	
		Polio	2 doses	
		haemophilus influenzae type B	2 doses	
		Pneumococcal	2 doses	
	
12 months
through 18 months of age	Diphtheria/Tetanus/Pertussis	3 doses	
		Polio	2 doses	
		haemophilus influenzae type B	2 doses; or
1 dose received when the applicant is 15 months of age or older.	
		Pneumococcal	3 doses if the applicant received 1 or 2 doses before 12 months of age; or
2 doses if the applicant has not received any previous doses or has received 1 dose on or after 12 months of age.	

19 months
through 23 months of age	Diphtheria/Tetanus/Pertussis	4 doses	
		Polio	3 doses	
		haemophilus influenzae type B	3 doses, with the final dose in the series received on or after 12 months of age, or 1 dose received when the applicant is 15
months of age or older.	
		Pneumococcal	4 doses; or
3 doses if the applicant received 1 or 2 doses before 12 months of age; or
2 doses if the applicant has not received any previous doses or has received 1 dose on or after 12 months of age.	
		Measles/Rubella1	1 dose of measles/rubella-containing vaccine received on or after 12 months of age; or the applicant demonstrates a
positive antibody test for measles and rubella from a U.S. laboratory.	
		Varicella	1 dose received on or after 12 months of age if the applicant was born on or after September 15, 1997, unless the applicant
has had a reliable history of natural disease.	

24 months and older	Diphtheria/Tetanus/Pertussis	4 doses	
		Polio	3 doses	
		haemophilus influenzae type B	3 doses, with the final dose in the series received on or after 12 months of age; or 1 dose received when the applicant is 15
months of age or older. Hib vaccine is not indicated for persons 60 months of age or older.	

Pneumococcal	4 doses if the applicant received 3 doses before 12 months of age; or 3 doses if the applicant received 2 doses before 12 months of age; or
2 doses if the applicant received 1 dose before 12 months of age or received 1 dose between 12 and 23 months of age; or 1 dose if no doses had been received prior to 24 months of age.
Pneumococcal vaccine is not indicated for persons 60 months of age or older.	
		Measles/Rubella1	1 dose of measles/rubella-containing vaccine received on or after 12 months of age; or the applicant demonstrates a
positive antibody test for measles and rubella from a U.S. laboratory.	
		Varicella	1 dose received on or after 12 months of age if the applicant was born on or after September 15, 1997, unless the applicant
has had a reliable history of natural disease.	
				
Elementary or Secondary School (K-12)	

4 years of age and older	

Diphtheria/Tetanus/ Pertussis 4, 5	doses, with at least 1 dose of diphtheria/tetanus/pertussis-containing vaccine received on or after 4 years of age if the applicant was born on or before September 15, 20002; or
doses, with at least 1 dose of diphtheria/tetanus/pertussis-containing vaccine received on or after 4 years of age if the applicant was born after September 15, 2000, but before September 15, 20032; or
doses with at least 1 dose of diphtheria/tetanus/pertussis-containing vaccine received on or after 4 years of age if the applicant was born on or after September 15, 20032, 3; and
1 time dose of tetanus/ diphtheria/acellular pertussis-containing vaccine (Tdap) for applicants in grades 7 and above, if born
on or after September 15, 2000; regardless of the interval since the last tetanus/diphtheria containing vaccine.	
		
Polio 7	doses, with at least 1 dose received on or after 4 years of age if the applicant was born on or before September 15, 2003; or
doses, with at least 1 dose received on or after 4 years of age if the applicant was born after September 15, 2003.6	
		Measles/Rubella1	2 doses of measles/rubella-containing vaccine; the first dose shall have been received on or after 12 months of age; the second dose shall have been received no less than 28 days after the first dose; or the applicant demonstrates a positive
antibody test for measles and rubella from a U.S. laboratory.	
		Hepatitis B	3 doses if the applicant was born on or after July 1, 1994.	
		
Varicella	dose received on or after 12 months of age if the applicant was born on or after September 15, 1997, but born before September 15, 2003, unless the applicant has had a reliable history of natural disease; or
doses received on or after 12 months of age if the applicant was born on or after September 15, 2003, unless the
applicant has a reliable history of natural disease.8	
1 Mumps vaccine may be included in measles/rubella-containing vaccine.
2 DTaP is not indicated for persons 7 years of age or older, therefore, a tetanus-and diphtheria-containing vaccine should be used.
3 The 5th dose of DTaP is not necessary if the 4th dose was administered on or after 4 years of age.
4 Applicants 7 through 18 years of age who received their 1st dose of diphtheria/tetanus/pertussis-containing vaccine before 12 months of age should receive a total of 4 doses, with one of those doses administered on or after 4 years of age
5 Applicants 7 through 18 years of age who received their 1st dose of diphtheria/tetanus/pertussis-containing vaccine at 12 months of age or older should receive a total of 3 doses, with one of those doses administered on or after 4 years of age.
6 If an applicant received an all-inactivated poliovirus (IPV) or all-oral poliovirus (OPV) series, a 4th dose is not necessary if the 3rd dose was administered on or after 4 years of age.
7 If both OPV and IPV were administered as part of the series, a total of 4 doses are required, regardless of the applicant’s current age.
8 Administer 2 doses of varicella vaccine, at least 3 months apart, to applicants less than 13 years of age. Do not repeat the 2nd dose if administered 28 days or greater from the 1st dose. Administer 2 doses of varicella vaccine to applicants 13 years of age or older at least 4 weeks apart. The minimum interval between the 1st and 2nd dose of varicella for an applicant 13 years of age or older is 28 days.