Colorado students who cannot receive one or more school-required vaccines because of a medical condition need this certificate on file at each school or child care. After checking Colorado's contraindications and precautions guidance, the provider marks each exempted vaccine as permanent or temporary with an expiration date and signs a statement that the vaccine would endanger the student's life or health.
The parent or guardian, or an adult or emancipated student, fills in student and school details. An APN, MD, DO or PA licensed in any US state or territory completes the vaccine table and signs with printed name, title, date, license number and licensing state.
Download the current version from the source each time; forms change without notice.
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
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An advanced practice nurse, a physician (MD or DO) or a physician assistant licensed to practice in any US state or territory. The signer prints name and title, dates the form, and gives a professional license number and the state or territory that issued it.
A permanent medical exemption is submitted to the school or child care once. A temporary exemption expires after the temporary until date the provider writes for each vaccine, and the school or child care monitors that date to know when the student can receive the vaccine.
The school-required vaccines: hepatitis B, DTaP, Hib, IPV, pneumococcal conjugate, MMR, varicella, Tdap, and Td or DT. The provider marks permanent or temporary for each one that applies, after reviewing Colorado's contraindications and precautions guidance for school-required vaccines.