|
Vaccine exemption forms for many states in the US,
Australia, Canada, New Zealand
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 ‘counselled’ you on the risks
of not vaccinating. This form can be obtained from Medicare or
Centrelink offices. ”
Austrialia 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): clopez@doh.state.nm.us
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 implimenting 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 wdh@state.wy.us
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
At the present time, not every state has their forms online. The
ones I have found are listed here. If your states forms are NOT online,
but you have a paper copy of them, please send me an original copy so I
can put the form online here, providing there is not a copyright printed
on the page. Even if there is a copyright, I would still like to have
an original copy of each state’s form for reference purposes. Send to
P.O. Box 6562, Lawton, Oklahoma, 73506-0562.
If you need legal assistance in regards to anything pertaining to
vaccination exemptions, vaccine injury, etc., please contact the Vaccine
Exemption Alliance.
For original post with hot links, go to
www.unhinderedliving.com/statevaccexemp.html
|