REQUEST FOR MEDICAL EXEMPTION
FROM MANDATORY IMMUNIZATION
SCHOOL FORM
PAGE 1 OF 4MAY 2021
INSTRUCTIONS FOR COMPLETION
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1. Fill out the form completely. ALL form elds are required except where noted as being optional.
a. Enter the name of the Student and other identifying information.
b. Check o each vaccine for which an exemption is requested.
i. For each vaccine for which an exemption is requested, check to indicate whether the exemption is
Temporary (indicate the date through which the exemption is valid) or Permanent.
ii. Check the ACIP contraindication/precaution applicable for each vaccine for which an exemption is requested.
c. If the contraindication/precaution is not included in Table 1, please put an “X” next to “Other” and fully
explain. Please be sure that the contraindication/precaution does not appear in Table 2, that there is a
valid contraindication/precaution noted for each vaccine for which an exemption is requested, and that the
contraindication/precaution is consistent with ACIP/AAP guidelines and established national standards for
vaccination practices.
2. Sign and date the Attestation Statement.
3. Provide a copy to the person requesting the medical exemption or directly to the school, preschool,
or child care center.
4. Keep a copy of the form for your records.
Medical contraindications and precautions for immunizations are based on the most recent General Recommendations
of the Advisory Committee on Immunization Practices (ACIP), available at https://www.cdc.gov/vaccines/hcp/acip-recs/
general-recs/contraindications.html or https://redbook.solutions.aap.org/redbook.aspx
Please check the website to ensure that you are reviewing the most recent ACIP information. Please note that the pres-
ence of a moderate to severe acute illness with or without fever is a precaution to administration of all vaccines. However,
as acute illnesses are short-lived, medical exemptions should not be submitted for this indication.
Name of Student: rst/middle/last Date of Birth:
Name of Parent/Guardian (if under 18): rst/middle/last Primary Phone:
Patient/Parent Home Address:
address 1 address 2 city state zip
Patient/Parent Email Address:
REQUEST FOR MEDICAL EXEMPTION
FROM MANDATORY IMMUNIZATION
SCHOOL FORM
PAGE 2 OF 4MAY 2021
Table 1. ACIP Contraindications and Precautions to Vaccination for Mandatory Vaccines
Vaccine Exemption Length ACIP Contraindications and Precautions (CHECK ALL THAT APPLY)
DTaP, Tdap Temporary
through:
Permanent
Contraindications
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component
Encephalopathy (e.g., coma, decreased level of consciousness,
prolonged seizures) not attributable to another identiable cause within 7
days of administration of a previous dose of DTP, DTaP, or Tdap
Precautions
Progressive neurologic disorder, including infantile spasms, uncontrolled
epilepsy, progressive encephalopathy; defer DTaP or Tdap until
neurologic status claried and stabilized
Guillain-Barré syndrome < 6 weeks after previous dose of tetanus-
toxoid-containing vaccine
History of Arthus-type hypersensitivity reactions after a previous dose of
diphtheria-toxoid-containing or tetanus toxoid-containing vaccine; defer
vaccination until at least 10 years have elapsed since the last tetanus
toxoid-containing vaccine
Inactivated
polio virus
vaccine (IPV)
Temporary
through:
Permanent
Contraindications
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component
Precautions
Pregnancy
MMR Temporary
through:
Permanent
Contraindications
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component
Pregnancy
Known severe immunodeciency (e.g., from hematologic and solid
tumors, receipt of chemotherapy, congenital immunodeciency, long-term
immunosuppressive therapy or patients with human immunodeciency
virus [HIV] infection who are severely immunocompromised)
Family history of congenital or hereditary immunodeciency in rst-
degree relatives (e.g., parents and siblings), unless the immune
competence of the potential vaccine recipient has been substantiated
clinically or veried by a laboratory test
Precautions
Recent (≤ 11 months) receipt of antibody-containing blood product
(specic interval depends on product)
History of thrombocytopenia or thrombocytopenic purpura
Need for tuberculin skin testing or interferon gamma release assay
(IGRA) testing
REQUEST FOR MEDICAL EXEMPTION
FROM MANDATORY IMMUNIZATION
SCHOOL FORM
PAGE 3 OF 4MAY 2021
Meningococcal
(MenACWY)
Temporary
through:
Permanent
Contraindications
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component
Precautions
Preterm Birth (MenACWY-CRM)
Varicella Temporary
through:
Permanent
Contraindications
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component
Known severe immunodeciency (e.g., from hematologic and solid
tumors, receipt of chemotherapy, congenital immunodeciency, long-
term immunosuppressive therapy or persons with HIV infection who are
severely immunocompromised)
Pregnancy
Family history of congenital or hereditary immunodeciency in rst-
degree relatives (e.g., parents and siblings), unless the immune
competence of the potential vaccine recipient has been substantiated
clinically or veried by a laboratory test
Precautions
Recent (≤ 11 months) receipt of antibody-containing blood product
(specic interval depends on product)
Receipt of specic antivirals (i.e., acyclovir, famciclovir, or valacyclovir)
24 hours before vaccination; avoid use of these antiviral drugs for 14
days after vaccination)
Use of aspirin or aspirin-containing products
Other. Please explain fully and attach additional sheets as necessary. Please be sure to check Table 2 below to
ensure that the condition is not one incorrectly perceived as a contraindication or precaution.
Attestation
I am a physician (M.D. or D.O) licensed to practice medicine in a jurisdiction of the United States or an advanced practice
nurse (N.P./P.A) licensed in a jurisdiction of the United States.
By signing below, I arm that I have reviewed the current ACIP Contraindications and Precautions and arm that the
stated contraindication(s)/precaution(s) is enumerated by the ACIP and consistent with established national standards for
vaccination practices. I understand that I might be required to submit supporting medical documentation. I understand that
any misrepresentation will result in referral to the appropriate licensing board and/or regulatory agency.
Healthcare Provider Name (please print): Specialty:
NPI Number: License Number: State of Licensure:
Practice Name:
Phone: Fax:
Email:
Address: City: State: Zip:
Signature: Date:
REQUEST FOR MEDICAL EXEMPTION
FROM MANDATORY IMMUNIZATION
SCHOOL FORM
PAGE 4 OF 4MAY 2021
Table 2. Examples of Conditions incorrectly perceived as contraindications or precautions
to vaccination* (i.e., vaccines may be given under these conditions)
Vaccine
Conditions incorrectly perceived as contraindications and precautions to vaccines
(i.e., vaccines may be given under these conditions)
General for MMR, Hib,
HepB, Varicella, PCV13,
MenACWY
• History of Guillain-Barré syndrome
• Recent exposure to an infectious disease
• History of penicillin allergy, other nonvaccine allergies, relatives with allergies, or
receiving allergen extract immunotherapy
DTaP • Fever within 48 hours after vaccination with a previous dose of DTP or DTaP
• Collapse or shock like state (i.e., hypotonic hyporesponsive episode) within 48 hours
after receiving a previous dose of DTP/DTaP
• Seizure ≤ 3 days after receiving a previous dose of DTP/DTaP
• Persistent, inconsolable crying lasting ≥ 3 hours within 48 hours after receiving a
previous dose of DTP/DTaP
• Family history of seizures
• Family history of sudden infant death syndrome
• Family history of an adverse event after DTP/DTaP
• Stable neurologic conditions (e.g., cerebral palsy, well-controlled seizures, or
developmental delay)
Hepatitis B (HepB) • Pregnancy
• Autoimmune disease (e.g., systemic lupus erythematosus or rheumatoid arthritis)
Inuenza, inactivated
injectable (IIV)
• Nonsevere (e.g., contact) allergy to latex, thimerosal, or egg
MMR • Breastfeeding
• Pregnancy of recipient’s mother or other close or household contact
• Recipient is female of child-bearing age
• Immunodecient family member or household contact
• Asymptomatic or mildly symptomatic HIV infection
• Allergy to eggs
Tdap • History of fever of ≥ 40.5° C (≥ 105° F) for < 48 hours after vaccination with previous
dose of DTP/DTaP
• History of collapse or shock-like state (hypotonic hyporesponsive episode) within 48
hours after receiving a previous dose of DTP/DTaP
• History of persistent, inconsolable crying lasting > 3 hours within 48 hours of receiving a
previous dose of DTP/DTaP
• History of extensive limb swelling after DTP/DTaP/Td that is not an Arthus-type reaction
• History of stable neurologic disorder
• Immunosuppression
Varicella • Pregnancy of recipient’s mother or other close or household contact
• Immunodecient family member or household contact
• Asymptomatic or mildly symptomatic HIV infection
• Humoral immunodeciency (e.g., agammaglobulinemia)
* For a complete list of conditions, please review the ACIP Guide to Contraindications and Precautions accessible at https://www.cdc.gov/vaccines/hcp/
acip-recs/general-recs/contraindications.html.
