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Record Keeping Ace Your Immunization Audit

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Use the following checklists to when examining your immunization records. For additional questions, contact a Disease Prevention Specialist at Johnson County Public Health at 356-6040.

Acceptable Certificates

Certificate bullet Click here to view a sample immunization certificate! Adobe Document

The following four forms of the Certificate of Immunization are accepted:

bullet 3 X 5 Certificate of Immunization Card Adobe Document
bullet 8 1/2 X 11 Certificate of Immunization Adobe Document
bullet Certificate of Immunization Exemption (Medical)- blue 3 X 5 card Adobe Document
bullet Certificate of Immunization Exemption (Religious)- blue 3 X 5 card Adobe Document


Immunization Certificate Checklists

2-18 Months Old
• 1 DTP
• 1 Polio
• 1 Hib
• Date each shot was given (mm/dd/yy)
• Physician or health official signature
• Date of Birth
• Doctor/Clinic/Source
• Clinic location *

 18 Months and Older (up to Kindergarten age)
• 3 DTP
• 3 Polio
• 3 Hib **
•1 MMR †
• Varicella † (or a history of natural disease as stated by a parent or guardian)
• Date each shot was given (mm/dd/yy)
• Physician or health official signature
• Date of Birth
• Doctor/Clinic/Source
• Clinic location *
* The location of the clinic must be written on the immunization record. Examples of acceptable alternatives for clinic name and location:
   Chicago Department of Public Health
   Saki Clinic, Saki Japan
Examples of unacceptable alternatives for clinic name and location:
   Chicago, IL
   Japan Omaha Public Schools

** If 3 doses of Hib have not been received by 18 months of age, only one dose of Hib vaccine should be administered after 15 months of age.

† " The shot must be given on or after the child’s first birthday

Notes About Medical/Religious Exemptions & Checklists

Medical
Only a medical doctor, doctor of osteopathic medicine, nurse practitioner, or physician assistant who is licensed in Iowa may sign a medical exemption. If a child’s medical professional feels that child should be exempt from the law for medical reasons, the medical professional may fill out a Certificate of Immunization Exemption. The exemption must also be signed by the child’s parent or guardian.

Religious
If a parent wishes their child to be exempt from the law because immunization conflicts with a religious belief, a Certificate of Immunization Exemption may be completed. The certificate must be signed by the parent, religion listed, and the card must be notarized.

Medical Exemption Checklist
• Child's name
• Date of birth
• Doctor's signature
• Date
• Date of expiration of vaccine
• Signature of parent or guardian 		Religious Exemption Checklist
• Child's name
• Date of birth
• Religious denomination
• Parent's signature
• Seal of Notary Public

Provisional Certificates *

Provisional certificates are available for children who have begun, but not completed required immunizations. To qualify for a provisional, the child must have received at least one dose of DTP/DTaP, polio, measles, rubella, and Hepatitis B. The provisional must be signed by a doctor or health official, and the child’s parent of guardian. The provisional expires after 120 days. Contact a disease prevention specialist at Johnson County Public Health for more information at (319) 356-6040.

* Children under 18 months of age are not eligible for a provisional certificate.