State forms clinicians sign for school and child care vaccine rules, from registry-printed certificates to medical exemption statements and TB clearances.
Schools and child care programs need proof of immunization, and the clinician's part is usually a certificate, a medical exemption or a TB clearance. Several certificates print from the state registry: Alabama's Certificate of Immunization from ImmPRINT, Florida's DH 680 from Florida SHOTS and South Carolina's D-4024 from SIMON. Iowa's Certificate of Immunization is a PDF the office signs, Pennsylvania's school card has a section for a physician-signed medical exemption, and Virginia's Report of Tuberculosis Screening documents TB clearance. This page lists 59 state forms.
Medical exemption rules vary the most. California exemptions are issued only in the CAIR-ME portal, Connecticut providers must enter each exemption in the DPH portal, and Oklahoma accepts a physician signature only. Maine, Massachusetts, New Hampshire and Texas post no state medical exemption form, so the clinician writes a statement. Mississippi's Form 139-M and North Carolina's DHHS 3995 go to the state for review. 15 forms have a Spanish version. Upload any fillable PDF to Vero and it becomes a template the whole clinic can use.
Official certificate showing a child's school-required immunizations and expiration date, required on file for every child in Alabama schools and licensed child care.
Formulario de Exención por Razones Médicas
Official ADHS format documenting a temporary or permanent medical exemption, or lab evidence/history of immunity, for school, preschool and child care immunization requirements.
Annual application for a medical, religious or philosophical exemption from child care/school immunization requirements; medical requests must include a physician statement reviewed by the Immunization Section Medical Director.
Issues a standardized temporary or permanent medical exemption from required school and child care immunizations, reviewable by CDPH.
Standard adult TB risk assessment that clinicians use to decide on TB testing, commonly accepted for employment, health care worker, college and other TB clearance requirements.
Standard pediatric TB risk assessment used to decide on TB testing, accepted by schools and child care programs that require TB screening at entry.
Documents TB risk assessment (and testing if indicated) required for K-12 school employees, contractors and volunteers, ending in a Certificate of Completion for the employer.
Certificado de Exención Médica
Certifies a medical condition that prevents a student from receiving one or more school-required vaccines (permanent or temporary until a set date).
Certificado de Exención No Médica
Religious or personal-belief exemption from school-required vaccines, obtained either through CDPHE's online education module or with a signing health care provider who gives immunization consultation.
Certifies that a student's remaining required school immunizations are in process per the DPH catch-up schedule so the student may attend.
Documents a medical contraindication/precaution exempting a child from required immunizations for child care, K-12 or higher education (the only exemption allowed since Public Act 21-6).
Lets a provider declare an alternative catch-up schedule for a preschool child whose religious exemption predates April 28, 2021.
Required certificate documenting a child's immunizations (Part A) or a temporary (Part B) or permanent (Part C) medical exemption for entry to preschool, K-12, licensed child care and family day care homes.
Form 3231Required certificate for every child in Georgia child care, pre-K, Head Start and K-12 showing required immunizations, including a medical exemption designation.
TB Document FDepartment-approved certificate of tuberculosis clearance required under HAR 11-164.2 for school entry, school/child care employment, food handlers in certain settings, and other covered groups.
Department-approved TB risk assessment used to decide whether testing is needed before issuing a Hawaii TB clearance.
TB Document HDepartment-approved screen for signs and symptoms of TB disease used in the TB clearance process.
Immunization Requirements Exemption Form, Preschool & K-12 (Spanish)
State form claiming a medical, religious or other exemption from Idaho preschool and K-12 immunization requirements.
Religious exemption from school immunizations and/or health, dental or eye examinations, which must carry the signature of the child's health care provider after the provider informs the family of the benefits and risks.
Vaccine Medical Exemption Form (Spanish)
Health care provider certification that a student qualifies for a medical exemption from Indiana school immunization requirements.
Certifies that a child has age-appropriate immunizations meeting Iowa requirements for licensed child care or school enrollment.
Allows provisional school/child care enrollment for up to 60 days for a child who has started but not completed required vaccines, or a transfer student.
Medical exemption from Iowa school/child care immunization requirements when vaccines would be injurious to the applicant or a household member, or would violate live-vaccine spacing.
Required certificate on file at every Kentucky child care facility and school showing a child's immunizations and current status with an expiration date; marked as a medical exemption for temporary or permanent contraindications.
Certificate of required immunizations that Louisiana schools must receive before enrollment under R.S. 17:170, prepopulated from the LINKS immunization registry.
Written medical exemption from Maine school, child care and camp immunization requirements, the only exemption allowed for schools since 2021.
Certifies a student's vaccine dates for Maryland preschool and K-12 admission and documents a permanent or temporary medical contraindication (or parent religious objection).
DPH-recommended pediatric TB risk assessment for school-aged children, documented on the school health form, to identify children who need TB infection testing.
Written medical exemption documenting a contraindication to a required vaccine for school, child care, camp or college entry under 105 CMR 220.000.
ID# 52799Minnesota K-12 immunization requirement sheet whose reverse side documents a medical exemption (provider-signed), a notarized non-medical exemption, or history of chickenpox.
Form 139-MPhysician request for a medical exemption from Mississippi school/child care vaccines, reviewed by the State Epidemiologist, who then issues the Certificate of Medical/Religious Exemption (Form 122).
Imm.P.12Medical Immunization Exemption (Spanish)
Signed certification that a student is exempt from one or more Missouri school/child care vaccines because immunization would endanger health or life, or because of documented disease or lab immunity.
Imm.P.14Immunizations in Progress (Spanish)
Lets a child who has begun a required vaccine series attend school or child care by documenting the scheduled next-dose appointment.
Montana's official certificate of immunization for pre-K through 12th grade, recording vaccine dates and medical or religious exemption status.
HES 101ADocuments vaccines for which a Montana student is medically contraindicated, with the contraindication or precaution for each.
Medical Exemption Form - Spanish
Medical provider statement that immunization against listed diseases would be injurious to the student or a household member, exempting the student from Nebraska school/child care requirements.
Certification that immunization against a particular disease may be detrimental to the child's health, valid for the period the provider specifies (RSA 141-C:20-c).
Standard New Jersey form for a temporary or permanent medical exemption from school, preschool or child care immunizations, with ACIP/AAP-consistent contraindications per vaccine and a provider attestation.
Certificate of Exemption from Immunization (Spanish)
Parent request to NMDOH for a medical or religious exemption from school/daycare immunizations; medical requests must attach a licensed provider's letter.
Physician statement of a medical exemption from New York school and child care immunization requirements (outside New York City), reviewed by the school under NYSDOH procedures.
DHHS 3987Lets an NC-licensed physician certify a medical exemption for contraindications adopted by the NC Commission for Public Health (10A NCAC 41A .0404), accepted by schools, child care and colleges without state review.
Physician request to the State Health Director for a medical exemption based on a contraindication not listed on DHHS 3987.
Single North Dakota certificate documenting a student's immunizations and any medical, history-of-disease, religious, philosophical or moral exemption for school and child care.
Physician certification that specified immunizations are medically contraindicated for a child attending Oklahoma school, child care or Head Start.
Required proof of vaccine education for an Oregon nonmedical (religious, philosophical or other) exemption; signed by a health care provider after counseling, or printed after the online module.
Physician-signed medical exemption for ACIP-recognized contraindications, approved by the local public health authority, for Oregon school and child care immunization requirements.
Pennsylvania school immunization card recording vaccine dates, with a Statement of Exemption section for a physician-signed medical exemption or a parent religious/philosophical exemption.
Provisional-enrollment plan listing the dates each remaining required vaccine will be given, signed by the provider, so a student missing doses may attend school.
The single DPH form that certifies a child's required immunizations for child care and K-12 and also serves as the certificate of medical exemption (SC Regulation 61-8).
Physician certificate that a required vaccine would be injurious to the health and well-being of the student or a household member, exempting the student from Texas school/child care requirements.
Medical exemption from Utah school and early childhood immunization requirements: parent's vaccination exemption form plus a provider notice that vaccination would endanger the student's life or health.
Medical (page 1, provider-signed) or religious (page 2) exemption from Vermont immunization requirements for undergraduate college students.
Medical Immunization Exemption Form (Child Care and Schools) - Spanish
Medical exemption from Vermont's Immunization Rule (18 V.S.A. 1123) for child care and K-12 when a vaccine is contraindicated or may be detrimental to health.
'To whom it may concern' TB clearance documenting risk assessment, symptom screen, TST/IGRA results and chest x-ray conclusions, used for school employment, child care, college and other screening requirements.
State TB risk assessment for persons over age six (separate tool for children under 6) used to decide on TB testing before issuing a TB screening report.
DOH 348-013Certificado del Estado de Vacunación (CIS)
Required record of a child's vaccinations for Washington school/child care, including a provider-signed section verifying chickenpox history or lab immunity.
DOH 348-106Certificado de Exención
Official state-seal form to exempt a child from school, child care or preschool vaccines for personal/philosophical or religious reasons (page 1, with practitioner counseling declaration) or medical reasons (page 2, practitioner-certified).
Physician request to the State Immunization Officer for a permanent or temporary (max 24 months) medical exemption from West Virginia school/child care vaccines, with supporting medical evidence.
F-04020LWisconsin school immunization record (Wis. Stat. 252.04, 120.12(16)) returned within 30 school days of admission; includes a clinician attestation of reliable varicella history and lab immunity, and references health/religious/personal conviction waivers.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Each state sets its own list. Oklahoma's Certificate of Medical Exemption accepts physicians only and says PA, nurse or ARNP signatures will be denied. North Carolina's DHHS 3987 and New York's DOH-5077 need a physician licensed in that state, and Texas accepts a statement only from an MD or DO. Colorado, Connecticut and New Jersey also accept advanced practice nurses, and Colorado and Connecticut accept PAs.
Only through CAIR-ME, the California Immunization Registry medical exemption website, since January 1, 2021. The parent applies first and gives the physician an application number. A California-licensed MD or DO then enters the exemption in CAIR-ME and prints the standardized form for the parent to give the school, and schools verify it in CAIR-ME. There is no paper form, and personal belief exemptions ended in 2016.
The New York State Department of Health issued a new DOH-5077 medical exemption statement that must be used right away for new exemptions. The old form stays valid for 2026-27 only for exemptions schools already accepted, and from July 1, 2027 only the new form counts. A New York-licensed physician lists each vaccine, the ACIP contraindication or precaution and the duration. Non-medical exemptions were repealed in 2019.
Hawaii requires TB Document F for students new to Hawaii schools and for school and child care staff, backed by the TB Document G risk assessment and TB Document H symptom screen. California school employees and volunteers need a TB risk assessment and Certificate of Completion, repeated every 4 years. Virginia's Report of Tuberculosis Screening records the risk assessment, symptoms, TST or IGRA results and chest x-ray findings.