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Effective Date: 



Updated: 7/2003


  • To provide documentation of immunization records for children certified for TANF.
  • To document evidence used to establish good cause for failure to comply with immunization requirements.


When to Prepare

Workers complete Form H1012 for each child certified for TANF at the first complete review after signing the PRA.

Workers update the form at each complete review as the child completes subsequent immunization visits.

Number of Copies

Complete an original only for each child in the TANF household.

Note: Staff may copy and file the actual immunization record provided by the client in lieu of completing Form H1012.


Maintain the original form in the case folder until the child has completed the required immunization visits.

Detailed Instructions

Step 1: Establish the child's age range and determine the number of immunization visits he must have.

Step 2: Look at his shot record and determine if he made the required number of visits. Do not count an immunization administered at birth as a required visit. An immunization is considered administered at birth if it is given between birth and seven days.

  • If he does not meet the visit requirement, determine if good cause exists.
  • If good cause does not exist, determine if he made a visit in the last two months. If he meets that requirement, give the child a good cause code 1.

Step 3: If the child still does not meet the immunization requirement,

  • at the initial complete review (application or periodic) after implementation of immunization policy
    • inform the client that immunizations must be up to date by the next review,
    • circle the needed immunizations on the immunization pamphlet and give to client,
    • refer the client to the nearest immunization provider, and
    • explain the financial penalty.
  • at a subsequent TANF review after informing clients of the immunization policy
    • explain and apply the financial penalty,
    • circle the needed immunizations on the immunization pamphlet and give to client,
    • refer the client to the nearest immunization provider, and
    • inform the client that she must provide verification that the child has immunizations before the financial penalty can be removed.