TX HHS Form H1012. Immunization Record

Form H1012, titled Immunization Record, is a documentation form used to track a child’s immunization history for eligibility, compliance, or review purposes. It records whether a child has received the minimum required immunization visits appropriate for their age, or whether a valid reason exists for not meeting those requirements.

This form is commonly used in benefit eligibility reviews, child-related case management, and compliance checks where proof of immunization or a recognized exemption must be documented in a consistent and verifiable way.

Purpose of Form H1012

The primary purpose of Form H1012 is to confirm whether a child meets age-based immunization requirements or qualifies for a recognized “good cause” exception. Rather than listing every vaccine dose individually, the form focuses on the number and timing of immunization visits, including required Measles, Mumps, and Rubella (MMR) vaccinations at specific ages.

The form helps agencies determine continued eligibility for programs, benefits, or services that require compliance with public health immunization standards.

When This Form Must Be Used

Form H1012 is required when immunization status must be reviewed or verified for a child’s case. Typical situations include:

• Eligibility determination or renewal for child-related assistance programs
• Compliance checks during case reviews
• Verification of immunization history when records are incomplete or summarized
• Documentation of a claimed exemption or alternate compliance reason

The form is generally not required if complete immunization records are already accepted in another approved format and no exemption is being claimed.

Who Is Authorized to Complete the Form

Form H1012 is typically completed by:

• Eligibility workers or case managers
• Authorized agency staff reviewing a child’s case
• Program staff verifying compliance documentation

Parents or guardians usually provide the underlying immunization records or exemption documentation, but they do not typically complete the form themselves.

Explanation of Key Sections

Case and Child Information

This section identifies the case and the child, including case name, case number, child’s name, and date of birth. Accuracy is essential because immunization requirements are strictly age-based.

Age-Based Immunization Requirements

This portion of the form outlines the minimum number of immunization visits required based on the child’s age range. As a child gets older, additional visits are required, and certain visits must include an MMR vaccination administered after specific birthdays.

MMR Immunization Dates

Staff enter the dates of immunization visits, with particular attention to MMR timing. Incorrect timing, even with the correct number of visits, may result in non-compliance.

Good Cause Code Assignment

If the child does not meet immunization visit requirements, this section documents whether a valid good cause applies. The form allows for alternate, medical, or religious reasons.

Documented Evidence of Good Cause

This section confirms that supporting documentation exists, such as a medical statement or written exemption, and records the applicable date.

Comments

This optional area allows staff to explain unusual circumstances, clarify records, or note follow-up actions.

Practical Tips for Completing Form H1012

• Verify the child’s exact age at the time of review before counting visits.
• Confirm that required MMR vaccinations meet both age and timing rules.
• Do not assume visit counts without supporting documentation.
• Attach or reference exemption documents when good cause is claimed.
• Use the comments section to clarify borderline cases.

Common Mistakes to Avoid

• Counting immunization visits that occurred too early
• Missing the MMR timing requirement
• Claiming good cause without documentation
• Using the wrong age category
• Leaving exemption fields incomplete

Legal and Regulatory Context

Form H1012 reflects state public health and program eligibility rules that link immunization compliance to child-related benefits and services. These requirements exist to protect public health while allowing limited, documented exceptions when appropriate.

Accurate completion of the form supports consistent decision-making and helps ensure that exemptions are properly justified and recorded.

Real-Life Situations Where This Form Is Used

• A caseworker reviews immunization compliance during a benefits renewal.
• A child’s records show fewer visits than required, and a medical exemption is evaluated.
• An eligibility review requires confirmation that MMR timing rules were met.
• Incomplete immunization records require a summarized compliance determination.

Documents Commonly Needed with This Form

• Official immunization records or printouts
• Medical exemption statements
• Religious exemption documentation, if applicable
• Prior case notes or eligibility determinations

Frequently Asked Questions

Does this form replace official immunization records?

No, it summarizes compliance but relies on underlying records.

Who assigns the good cause code?

Authorized staff assign it based on documented evidence.

Is one immunization visit enough for older children?

No, older age groups require multiple visits.

Is an MMR vaccine always required?

Yes, unless a valid exemption applies.

Can exemptions be claimed without proof?

No, documentation is required.

What happens if requirements are not met?

The case may require follow-up or corrective action.

Related Forms

• Medical Exemption Statement
• Religious Exemption Documentation
• Child Eligibility Review Forms
• Case Action Worksheets

Form Details

• Form Name: Immunization Record
• Form Number: H1012
• Region: Texas
• Revision Date: September 1996