Vaccine Exemption Forms For States

Recently LowFatDietPlan.org has begun to compose a series on the pros and cons along with the dangers of having your children vaccinated. Along with this awareness we have comprised a list of exemption forms for the states that enable vaccine exemption. Please understand your rights in regards to the choice of whether to vaccinate you child or not, and if need be print one of these forms out and use it for good cause.

If you need legal assistance in regards to anything pertaining to vaccination exemptions, vaccine injury, etc., please contact the Vaccine Exemption Alliance as they are well versed in handling these matters.

Alaska – http://www.vaclib.org/pdf/ak.pdf

Alabama – (3) A written objection from the parent or guardian of a student based on religious tenets and practices shall be submitted in person by the parent or guardian to the County Health Department for issuance of a Certificate of Religious Exemption from the required immunizations or testing. A licensed physician can provide individual exemption from the required immunizations or testing on a Certificate of Medical Exemption. The Certificate of Religious Exemption and the Certificate of Medical Exemption will be on forms approved by the Alabama Department of Public Health and will be accepted in lieu of the Certificate of Immunization.

Authority: Code of Alabama, 1975, Section 16-30-5, et. seq.
Author: Donald E. Williamson, M.D.; Charles H. Woernle, M.D., M.P.H.
History: October 1, 1982; Amendment June 11, 1993; Amended: Filed
1/17/97, Effective 2/21/97.

Arizona – Request for Exemption to Immunization – School (English)
http://www.kyrene.org/health/forms_book/requestimmexept_schools.pdf

Request for Exemption to Immunization – School (Spanish)
http://www.kyrene.org/health/forms_book/RequestSpanExempImmunSchls.pdf

Request for Exemption to Immunization – Child Care (English)
http://www.kyrene.org/health/forms_book/RequestExemptImmunChildCare.pdf

Request for Exemption to Immunization – Child Care (Spanish)
http://www.kyrene.org/health/forms_book/RequestSpanExemptImmunChildCare.pdf

Schools have on file a form to be filled in by parent/guardian to refuse vaccines on philosophical  grounds.  Exact info here:

http://www.azavenue.com/kelly/Arizona%20Rules%20and%20Regulations.htm

15-872 . Proof of immunization; noncompliance; notice to parents; civil immunity
Exemption information and form
A. The director of the department of health services, in consultation with the superintendent of public instruction, shall develop by rule standards for documentary proof.
B. A pupil shall not be allowed to attend school without submitting documentary proof to the school administrator unless the pupil is exempted from immunization.

Australia – “The exemption may be religious, medical or conscientious objection. To claim these objections requires a form to be signed by your GP stating that s/he has ‘counseled’ you on the risks of not vaccinating. This form can be obtained from Medicare or Centrelink offices. ”

Australia conscientious exemption form in PDF format http://www.hic.gov.au/CA256976001D0618/Lookup/PDF_GENERAL_ACIR/$file/cfrm_acir_objection.pdf

Medical Objection link … http://www.hic.gov.au/CA256976001D0618/Lookup/PDF_GENERAL_ACIR/$file/cfrm_acir_contraindication.pdf

The forms above can be found at: http://www.hic.gov.au/yourhealth/forms/index.htm

Canada – Exemption information and form http://www.attached-mom.com/vaccanada.asp

Statement of Exemption the official Ontario Canada form here. Page 2 is in French.
Link to PDF exemption file http://www.gov.on.ca/MOH/english/forms/pdf/7470-64_.pdf

California – http://www.gval.com/legal.htm (California Health and Safety Code Section 120365). This is the “personal beliefs” exemption in California law.

The exemption is fairly easy to exercise. Each student in California is required to submit a “California School Immunization Record” to be admitted to school (California Health and Safety Code Section 12-375).

On the reverse of the form is the following statement: “I hereby request exemption of the child, named in the front, from the immunization requirements for school/child care center entry because these immunizations are contrary to my beliefs. I understand that in case of an outbreak of any of these diseases, the child may be temporarily excluded from school for his/her protection.” To exercise the exemption, you simply sign the immunization record under this statement.

There is another exemption which is available, although it is more difficult to exercise because a medical opinion is necessary. If immunization is “contraindicated”, that is, considered to be potentially harmful to the child for medical reasons, an exemption is granted upon the filing with of “a written statement by a licensed physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization…” (California Health and Safety Code Section 120370).

Colorado – http://www.cdphe.state.co.us/ps/mch/imm/immhom.asp

Section 15 Colorado Rules, Regulations and Laws

2001 Form

1997 Form

A. Medical exemption – By submitting to the student’s school a Certificate of Immunization with the statement of medical exemption signed by a physician licensed to practice medicine or osteopathic medicine in any state or territory of the United States indicating that the physical condition of the student is such that immunizations would endanger his/her life or health or is medically contraindicated due to other medical conditions.

B. Religious exemption – By submitting to the student’s school a Certificate of Immunization with the statement of religious exemption signed by the parent(s), or the emancipated student, indicating that the parent(s), or emancipated student is an adherent to a religious belief whose teachings are opposed to immunizations.

C. Personal belief exemption – By submitting to the student’s school a Certificate of Immunization with the statement of personal exemption signed by the parent(s), or the emancipated student, indicating that the parent(s), or emancipated student has a personal belief that is opposed to immunizations.

D. In the event of an outbreak of disease against which immunization is required, no exemption or exception from immunization shall be recognized and exempted persons may be subject to exclusion from school and quarantine.

State Requirements …says to state exemption on reverse side of Immunization Certificate.

Colorado Vaccination & Immunization Laws & Exemptions

Connecticut – http://www.vaclib.org/pdf/ct.pdf

Florida – Florida fl.pdf file 38k Florida’s HRS Form 681. Page 9 of the document is what is printed out on blue paper and signed by HRS caseworker.

Florida Case History on Religious Exemption

Sample Exemption letter for Florida to turn in to Health Dept to get the DH Blue Form #681
http://www.know-vaccines.org/exemption.html

Georgia – No official state form. A written exemption which must be notarized

Iowa – To order an Iowa religious exemption form or other forms
http://www.idph.state.ia.us/common/pdf/immunization/literature_order_form.pdf

One helpful source of information is: Network of Iowa Christian Home Educators (NICHE) found at  http://www.the-niche.org/index.html

Iowa 4 H Club Center
Waiver for persons (youth or adult) Requesting Exemption from Medical Examinations or treatment.
http://www.extension.iastate.edu/4hcenter/CampMedicalWaiver.PDF

Iowa administrative code in pdf format
http://www.idph.state.ia.us/common/pdf/immunization/iowas_imm_code_ch7_641.pdf

Idaho – Exemption Forms Idaho – Text file Idaho – .doc file

Immunization Certificate of Exemptions from Boise, Idaho schools.

This is a Spanish Form: PDF exemption file

Serbo Croatian: Link to PDF exemption file

Farsi language: Link to PDF exemption file

Illinois – Illinois: write to IDPH (or HRS) for their exemption forms. Can also be a written form.
(Illinois Dept of Public Health or Human Resource Services)

Indiana – Indiana: below is posted what one parent did for religious exemption…

The number in Indiana Code is 20-8.1-7-9.5 section 2a for the religious exemption.
I [a parent] wrote up & notarized my own using the code #’s saying —

In accordance with Indiana Code # …….I certify that the administration of vaccine & other immunizing agents to my child,———-,is contrary to both ————- & my personal religious beliefs,held either individually or jointly with others, and I therefore request that my child be exempt from the immunization requirements of the Indiana State Statute 9.5.

<>Kansas – Kansas requirements, religious exemption allowed:

Immunization information and KCI forms are available at schools, at most health care providers and at the Wichita-Sedgwick County Department of Community Health, 1900 E. 9th, Wichita, KS 67214, or call 268-8441.

Kansas Certificate of Immunization (KCI Form) http://www.kdhe.state.ks.us/bcclr/forms/CCL.007%20Exemption%20from%20Immunization%208-2002.pdf

Kansas Certificate of Immunization (KCI Form) Form B Medical Exemption
http://www.kdhe.state.ks.us/immunize/download/kci_form_b.pdf

Kentucky – 3) A local health department, physician, or other licensed health facility administering immunizations may obtain the following immunization certificates from the Cabinet for Health Services:

(a) “Commonwealth of Kentucky Immunization Certificate”;
(b) “Commonwealth of Kentucky Certificate of Medical Exemption”;
(c) “Commonwealth of Kentucky Childhood Immunization Law Certificate of Religious Exemption”; or
(d) “Commonwealth of Kentucky Provisional Immunization Certificate”.
——————————————————————————————————————– Section 5. Incorporation by Reference. (1) The following material is incorporated by reference:
(a) “Commonwealth of Kentucky Immunization Certificate (EPID 230), revised 9/2002″;
(b) “Commonwealth of Kentucky Provisional Immunization Certificate (EPID 230A), revised 9/2002″;
(c) “Commonwealth of Kentucky Certificate of Medical Exemption (EPID 230B), revised 9/2002″; and
(d) “Commonwealth of Kentucky Childhood Immunization Law Certificate of Religious Exemption (EPID 230C), revised 9/2002″.

http://www.lrc.state.ky.us/kar/902/002/060.htm

214.036 Exceptions to testing or immunization requirement.
Nothing contained in KRS 158.035, 214.010, 214.020, 214.032 to 214.036, and 214.990 shall be construed to require the testing for tuberculosis or the immunization of any child at a time when, in the written opinion of his attending physician, such testing or immunization would be injurious to the child’s health. Nor shall KRS 158.035, 214.010, 214.020, 214.032 to 214.036, and 214.990 be construed to require the immunization of any child whose parents are opposed to medical immunization against disease, and who object by a written sworn statement to the immunization of such child on religious grounds. Provided, however, that in the event of an epidemic in a given area, the Cabinet for Health Services may, by emergency regulation, require the immunization of all persons within the area of epidemic, against the disease responsible for such epidemic. Effective: July 15, 1998 History: Amended 1998 Ky. Acts ch. 426, sec. 396, effective July 15, 1998. — Amended 1980 Ky. Acts ch. 55, sec. 1, effective July 15, 1980. — Amended 1976 Ky. Acts ch. 128, sec. 4. — Amended 1974 Ky. Acts ch. 74, Art. VI, sec. 107(3). — Amended 1968 Ky. Acts ch. 87, sec. 4. — Created 1962 Ky. Acts ch. 95, sec. 4.

Maine – Here’s a link to the Maine exemption letter form. It is apparently printed out on a school letterhead.   http://www.state.me.us/education/sh/exemption%20form.doc

Maryland – Description : Maryland DHMH 896 (Sign & date religious objection or get medical doctor to sign medical contradiction.  Religious exemption checked and signed at the bottom of page one. Revised 04/01 http://www.howard.k12.md.us/healthserv/DHMH896.pdf

Massachusetts – Immunization Exemptions and Vaccine Preventable Disease Exclusion Guidelines in School Settings May 2003

Definition of Allowable Exemptions There are two situations in which children who are not appropriately immunized may be admitted to school:

1) a medical exemption is allowed if a physician submits documentation that an immunization is medically contraindicated; and

2) a religious exemption is allowed if a parent or guardian submits a written statement that immunizations conflict with their sincere religious beliefs.

Philosophical exemptions are not allowed by law in Massachusetts, even if signed by a physician. Only medical and religious exemptions are acceptable. These exemptions must be kept in the students files at school (105 CMR 220.000 and M.G.L. c.76, ss. 15 and 15C).

Source: http://www.geocities.com/HotSprings/Villa/3120/mass.htm

Michigan  – Immunization Waiver Form

Religious, personal or Medical exemption.
Source: Michigan Opposing Mandatory Vaccines:
P.O. Box 1121, Troy, MI 48099-1121
Phone: (810) 447-2418.

Minnesota – PUPIL HEALTH IMMUNIZATION RECORD

http://www.health.state.mn.us/divs/dpc/adps/forms/pupilrec.pdf

Has provision for both medical exemption and “Conscientious exemption:
No student is required to have an immunization which is contrary to the conscientiously held beliefs of his/her parent or guardian. To receive this exemption,a parent or legal guardian must complete and sign the following statement and have it notarized.”

Exemption information and form This is an online form that one can copy and paste from the html
http://www.duluth.k12.mn.us/nurses/exemption.html

Mississippi – Write to state for:
Certificate of Medical Exemption (Form 122) ~~~ Children
Certificate of Medical Exemption (Form 132) ~~~ Adults

Missouri – Rules of Department of Health in PDF format: http://mosl.sos.state.mo.us/csr/19csr/19c20-28a.pdf

PDF file of the form ordering instructions.
http://www.dhss.state.mo.us/warehouse/580-039.pdf

HTML file of the form ordering instructions: http://www.dhss.state.mo.us/warehouse/e-f-vptde.html

Montana – 20-5-405. Medical or religious exemption.
(1) When a parent, guardian, or adult who has the responsibility for the care and custody of a minor seeking to attend school or the person seeking to attend school, if an adult, signs and files with the governing authority, prior to the commencement of attendance each school year, a notarized affidavit on a form prescribed by the department stating that immunization is contrary to the religious tenets and practices of the signer, immunization of the person seeking to attend the school may not be required prior to attendance at the school. The statement must be maintained as part of the person’s immunization records. A person who falsely claims a religious exemption is subject to the penalty for false swearing provided in 45-7-202.

Religious Exemption Form for school:

Gallatin Gateway School in Southwest Montana Religious exemption affidavit form. Can be used throughout the state for other schools. (Updated in 2000)

http://www.gallatingatewayschool.com/media/pdf/forms/ReligiousExemptForm.pdf

Montana Law & links Re exemptions: http://www.ShotFreeInMontana.com

North Carolina – immunization pursuant to section 15-873.

Medical exemption statement for North Carolina. http://www.immunizenc.org/images/3987%20medical%20exemption%208-02.pdf

North Dakota – Certificate of Immunization http://www.health.state.nd.us/disease/immune/cofimm.pdf

Check off religious, moral, personal, etc…must get original from health dept as there are carbon copies. Top white copy is turned in to school. Parent keeps yellow copy.

Nebraska -

http://www.ops.org/scs/hs/Public/Immunization.Waiver.pdf
Would be good to print the statute on the back of the page.

Nebraska
­ Neb. Rev. Stat. § 79-221 (2)
Immunization shall not be required for a student’s enrollment in any school in this state if he or she submits to the admitting official either of the following:

An affidavit signed by the student or, if he or she is a minor, by a legally authorized representative of the student, stating that the immunization conflicts with the tenets and practice of a recognized religious denomination of which the student is an adherent or member or that immunization conflicts with the personal and sincerely followed religious beliefs of the student.

Nebraska Administrative Code www.sos.state.ne.us/local/regsearch/Rules/Health_and_Human_Services_System/Title-173/Chapter-3.pdf

New Hampshire -

TITLE X
PUBLIC HEALTH
CHAPTER 141-C
COMMUNICABLE DISEASE
Section 141-C:20-c
141-C:20-c Exemptions. – A child shall be exempt from immunization if:
I. A physician licensed under RSA 329, or a physician exempted under RSA 329:21, III, certifies that immunization against a particular disease may be detrimental to the child’s health. The exemption shall exist only for the length of time, in the opinion of the physician, such immunization would be detrimental to the child. An exemption from immunization for one disease shall not affect other required immunizations.
II. A parent or legal guardian objects to immunization because of religious beliefs. The parent or legal guardian shall sign a notarized form stating that the child has not been immunized because of religious beliefs.

Source. 1987, 193:7, eff. Jan. 1, 1988. 2001, 18:1, eff. Jan. 1, 2002.

http://www.gencourt.state.nh.us/rsa/html/X/141-C/141-C-20-c.htm

The notarized form for religious exemptions is supplied by the school.

New Jersey – No official state form. A written exemption. May be a good idea to notarize.

See 22 page exemption letter, either HTML or .PDF file.

New Jersey school – New Jersey Children’s Center at Bankers Trust (Harborside)
http://www.childrenfirst.com/parents/mf_nj.PDF
The exemption is on page 4. This is their own exemption.

New Mexico – Parents have the right to refuse immunizations for medical, religious, or
philosophical reasons. Medical exemptions must be signed by the child’s physician
on letterhead paper and a copy sent to the NM Immunization Program.
Religious/ philosophical exemption forms must be filled out, officially notarized, and
returned to the NM Immunization Program for filing. A copy will be given to
the parent or guardian to present to the school/daycare. Immunization exemption
forms must be renewed and resubmitted every school year.

Download here:

http://www.health.state.nm.us/Preview/Immunize/NMID/Pages/Public/sched/COform.pdf

Completed medical or CO exemption forms must be returned to the Immunization
Program either by:

1) Mail:

Celina Lopez
Attn: Immunization Exemption Form Immunization Program
NM Department of Health
1190 St. Francis Dr.
Santa Fe, NM 87505

2) Fax: 505-827-1741 or

3) Or electronically (scanned and emailed):  [email protected]

New York – One answer we received is this:
As far as a religious exemption goes… In NYS there is not have form to fill out per se…The individual filing must submit a letter to the appropriate school official stating that they hold sincere and genuine religious beliefs that contraindicate vaccinations.  See
http://www.vaclib.org/exempt/newyork.htm#letters

New Zealand – New Zealand does not have compulsory vaccination or financial penalties for non-vaccinators (yet). They do require a vaccination certificate on entry into childcare or school. This is to identify non-vaccinated children during a disease outbreak. Details of the policy can be found in this Press Release.

http://vaxchoice.crosswinds.net/vaccination/exemption.html

Ohio – This one is listed for Defiance City, but it cites Ohio state code in the
document, and would be accepted for all Ohio schools.

http://www.neola.com/defiancecity-oh/forms/fm5320F1.pdf

Oklahoma – Medical, Religious, and Personal Exemptions Allowed.  You can pick up a copy of ODH Form 216-A Certificate of Exemption at your local Health Department or Board of Education.  Or you can print it out here:

http://www.unhinderedliving.com/exemptionform.html

I obtained this copy of the exemption form from my local board of education.  The original has a white top copy and a yellow second copy.  One copy is for the school, and the other copy is to be sent to the state health department.  When I obtained this from the local school board, they were out of originals and were just making xerox copies to hand out.  I asked if I could have more copies to give to my vaccine awareness group, and they said to just make more xerox copies myself.  There is no copyright on the form.  Each person needs two copies to send in, and one copy to keep for themselves if they want.  As far as I know, the Oklahoma Health Department does not have this form online anywhere.

Oregon – If you want a great letter written by a lawyer to an Oregon School Board
http://www.childscreen.org/Letter%20to%20the%20Oregon%20School%20District.htm

Pennsylvania – Medical and Religious exemptions allowed.

Download the form here:  http://www.unhinderedliving.com/Vaccine.jpg

South Carolina – http://www.geocities.com/HotSprings/Villa/3120/south_carolina.htm

(D) A South Carolina Certificate of Special Exemption signed by the school principal, authorized representative, or day care director may be issued to transfer students while awaiting arrival of medical records from their former area of residence or to other students who have been unable to secure immunizations or documentation of immunizations already received. A South Carolina Certificate of Special Exemption may be issued only once and is valid for only thirty calendar days from date of enrollment. At the expiration of this special exemption, the student must present a valid South Carolina Certificate of Immunization, a valid South Carolina Certificate of Medical Exemption, or a valid South Carolina Certificate of Religious Exemption.

Tennessee – Write to State for: Tennessee: TCA 49-6-5001(b)(2) ~~~ it’s a green form

Texas – El Paso Independent School district’s s religious exemption form for download.
http://www.episd.org/Schools/healthservices/immaffrelpg1.pdf

As of September 1, 2003, Texas is implementing an exemption to include anybody who wants to use it “for reasons of conscience, including religious beliefs.”
For more information see:   http://www.vaccineinfo.net/harassment/report.pdf

Utah – Description : Utah School Immunization Record (If a religious exemption is claimed, a Religious Exemption Form must be completed & signed by the parent. The Religious Exemption Form is obtained from local health dept. A local health dept. rep. must witness & sign the Religious Exemption Form giving the WHITE & YELLOW copies to the parent. The parent will present WHITE copy to school or daycare official. WHITE copy must be attached to record. PINK copy remains w/health dept. YELLOW copy remains w/parent

Virginia – This waiver form goes with the official Virginia Form CRE-1 which has to be turned in. The Form CRE-1 has to be notarized by a notary and also some universities also require signature from clergy. Clergy can either sign the same form or just write the exemptions themselves, or they could possibility sign Dr. Horowitz’s waiver form under the parents signature. Good idea to cover all bases.

PDF file of form CRE-1 Text file MS .doc ver7.0

Virginia Meningococcal Vaccine Waiver Form .PDF file

Washington -

Washington State .pdf file 35k
Washington State .pdf file in Spanish [cis99spn.pdf]
Washington State Vaccine Form & Exemption (French) 19cisfren.pdf 25k

Washington State ADDITIONAL LANGUAGE FORMS AVAILABLE:
Certificate of Immunization Status Forms:
Statement of Exemptions are on back of forms.
Check and sign, and you have the exemption!
Available in all these languages!

English

Spanish

French

Albanian

Amharic

Arabic

Punjabi

Bosnian

Russian

Cambodian

Somali

Chinese

Tagalog

Haitian Creole

Laotian

Thai

Tigrigna

Japanese

Urdu

Korean

Vietnamese

Portuguese

These came off of this website below….
http://www.doh.wa.gov/cfh/immunize/formpubs.htm#CIS

West Virginia – Only medical exemptions currently allowed.  See the
website of West Virginians for Vaccine Exemptions

Wyoming – Religious and Medical exemptions allowed as of February, 2003.

Contact the following for a copy of the exemption form:

Wyoming Department of Health
Web site http://wdhfs.state.wy.us/WDH/
e-mail [email protected]
Brent D. Sherard, M.D., Interim Director and State Health Officer
117 Hathaway Building
Cheyenne, WY 82002

Wyoming Vaccination Liberation Home page -
http://www.vaclib.org/chapter/wyhome.htm

Interesting Wyoming court case
IN THE SUPREME COURT, STATE OF WYOMING, reversal of denial of medical exemption.
courts.state.wy.us/2001opn/2001WY28.pdf

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Comments

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