Form 8 Certificate of Immunization - Iowa

Form 8 or the "Certificate Of Immunization" is a form issued by the Iowa Department of Public Health.

The form was last revised in January 1, 2013 and is available for digital filing. Download an up-to-date Form 8 in PDF-format down below or look it up on the Iowa Department of Public Health Forms website.

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PAGE 1 OF 2 | FORM 8
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,
Varicella
Tetanus,
Chicken Pox
If patient has a history
Pertussis
of natural disease
DTaP/DTP/DT/
write “Immune to
Td/Tdap
Varicella”
Pneumococcal
PCV/PPV
Meningococca
l
MCV4/MPSV4
Polio
IPV/OPV
Hepatitis A
Measles,
Rotavirus
Mumps,
Rubella
MMR
Haemophilus
influenzae
type b
Hib
Human
Papilloma
Virus
HPV
Hepatitis B
Other
January 2013
PAGE 1 OF 2 | FORM 8
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,
Varicella
Tetanus,
Chicken Pox
If patient has a history
Pertussis
of natural disease
DTaP/DTP/DT/
write “Immune to
Td/Tdap
Varicella”
Pneumococcal
PCV/PPV
Meningococca
l
MCV4/MPSV4
Polio
IPV/OPV
Hepatitis A
Measles,
Rotavirus
Mumps,
Rubella
MMR
Haemophilus
influenzae
type b
Hib
Human
Papilloma
Virus
HPV
Hepatitis B
Other
January 2013
IMMUNIZATION REQUIREMENTS
PAGE 2 OF 2 | FORM 8
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
Less than 4
This is not a recommended administration schedule, but contains the minimum requirements for participation in licensed child care. Routine vaccination
months of age
begins at 2 months of age.
Diphtheria/Tetanus/Pertussis
1 dose
4 months
Polio
1 dose
through 5
haemophilus influenzae type B
1 dose
months of age
Pneumococcal
1 dose
Diphtheria/Tetanus/Pertussis
2 doses
6 months
Polio
2 doses
through 11
haemophilus influenzae type B
2 doses
months of age
Pneumococcal
2 doses
Diphtheria/Tetanus/Pertussis
3 doses
Polio
2 doses
12 months
2 doses; or
through 18
haemophilus influenzae type B
1 dose received when the applicant is 15 months of age or older.
months of age
3 doses if the applicant received 1 or 2 doses before 12 months of age; or
Pneumococcal
2 doses if the applicant has not received any previous doses or has received 1 dose on or after 12 months of age.
Diphtheria/Tetanus/Pertussis
4 doses
Polio
3 doses
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
haemophilus influenzae type B
months of age or older.
19 months
4 doses; or
through 23
Pneumococcal
3 doses if the applicant received 1 or 2 doses before 12 months of age; or
months of age
2 doses if the applicant has not received any previous doses or has received 1 dose on or after 12 months of age.
1 dose of measles/rubella-containing vaccine received on or after 12 months of age; or the applicant demonstrates a
1
Measles/Rubella
positive antibody test for measles and rubella from a U.S. laboratory.
1 dose received on or after 12 months of age if the applicant was born on or after September 15, 1997, unless the applicant
Varicella
has had a reliable history of natural disease.
Diphtheria/Tetanus/Pertussis
4 doses
Polio
3 doses
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
haemophilus influenzae type B
months of age or older. Hib vaccine is not indicated for persons 60 months of age or older.
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
24 months
Pneumococcal
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
and older
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.
1 dose of measles/rubella-containing vaccine received on or after 12 months of age; or the applicant demonstrates a
1
Measles/Rubella
positive antibody test for measles and rubella from a U.S. laboratory.
1 dose received on or after 12 months of age if the applicant was born on or after September 15, 1997, unless the applicant
Varicella
has had a reliable history of natural disease.
3 doses, with at least 1 dose of diphtheria/tetanus/pertussis-containing vaccine received on or after 4 years of age if the
2
applicant was born on or before September 15, 2000
; or
4 doses, with at least 1 dose of diphtheria/tetanus/pertussis-containing vaccine received on or after 4 years of age if the
Diphtheria/Tetanus/
2
applicant was born after September 15, 2000, but before September 15, 2003
; or
4, 5
Pertussis
5 doses with at least 1 dose of diphtheria/tetanus/pertussis-containing vaccine received on or after 4 years of age if the
2, 3
applicant was born on or after September 15, 2003
; 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.
3 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;
4 years of age
or
7
Polio
and older
6
4 doses, with at least 1 dose received on or after 4 years of age if the applicant was born after September 15, 2003.
2 doses of measles/rubella-containing vaccine; the first dose shall have been received on or after 12 months of age; the
1
second dose shall have been received no less than 28 days after the first dose; or the applicant demonstrates a positive
Measles/Rubella
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.
1 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
Varicella
2 doses received on or after 12 months of age if the applicant was born on or after September 15, 2003, unless the
8
applicant has a reliable history of natural disease.
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 5
dose of DTaP is not necessary if the 4
dose was administered on or after 4 years of age.
th
th
4
Applicants 7 through 18 years of age who received their 1
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
st
of age
5
Applicants 7 through 18 years of age who received their 1
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
st
years of age.
6
If an applicant received an all-inactivated poliovirus (IPV) or all-oral poliovirus (OPV) series, a 4
dose is not necessary if the 3
dose was administered on or after 4 years of age.
th
rd
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 2
dose if administered 28 days or greater from the 1
dose. Administer 2 doses of varicella vaccine to
nd
st
applicants 13 years of age or older at least 4 weeks apart. The minimum interval between the 1
and 2
dose of varicella for an applicant 13 years of age or older is 28 days.
st
nd

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