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NY DOH-5077: Medical Exemption Statement for School

Outside New York City, a child can attend school or child care without a required vaccine only with this medical exemption signed by a New York-licensed physician. The revised form (07/26) asks which vaccines are exempted, the medical basis tied to ACIP contraindications or precautions, and how long the contraindication lasts. The school principal or designee decides whether to accept it.

Who completes it

A physician (MD or DO) licensed in New York State completes and signs the whole statement, certifying under Public Health Law Section 2164 that each listed vaccine would be detrimental to the child's health. The school records whether it is accepted.

Submitting and payment

How to submit it
The parent or guardian gives the signed statement to the school or child care, whose principal or designee reviews it, may consult its medical director and may forward it to the NYSDOH Bureau of School Immunizations for a recommendation.

Good to know

  • Exemptions last no more than one year and must be resubmitted annually. New exemptions must use the new form now; from July 1, 2027 only the new form is valid.
  • The form lists reasons that are never valid contraindications, including egg allergy, autism, controlled seizures, mild illness, family history of reactions or seizures, MTHFR mutation and parental requests to delay.
  • Vaccines that can be checked are DTaP, Tdap, Td, polio, hepatitis B, MMR, varicella and MenACWY, plus PCV and Hib for children up to their fifth birthday.
  • Students on school-provided homebound or remote instruction are covered; children homeschooled by a parent are not. New York City schools use a separate NYC medical exemption form.

Get the official form

Download the current version from the source each time; forms change without notice.

Immunization Requirements for School Attendance/Medical Exemption Statement for Children 0-18 Years of Age

Official pagePDF

How this list is checked

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.

Frequently asked questions

Can a nurse practitioner sign New York's DOH-5077 medical exemption?

No. The form must be completed and signed by a physician licensed in New York State, with an MD or DO degree and NYS license number. The physician certifies under Public Health Law Section 2164 that the immunization would be detrimental to the child's health.

How long is a New York school medical exemption valid?

No more than one year. Requests must be resubmitted annually, and the school notifies the parent when renewal is due. Once accepted as meeting Public Health Law 2164, the student is deemed compliant and may attend for that school year.

What if the school denies the medical exemption?

The school may first ask for more documentation and allow up to 14 days. Outside New York City, a parent has 30 days from the district's written denial to file a 310 appeal with the Commissioner of Education. A student may stay in school while NYSDOH reviews a forwarded request.