New Jersey uses this standard form to exempt a student from school, preschool or child care immunization requirements on medical grounds. The provider marks each vaccine, chooses a temporary exemption with an end date or a permanent one, describes the contraindication or precaution, and signs an attestation that it matches ACIP or AAP Red Book guidance. The October 2026 edition runs three fillable pages.
A physician (MD or DO) or advanced practice nurse licensed in any US jurisdiction completes the whole form, including student details, the vaccine table and the signed attestation with NPI, license number and state of licensure.
Download the current version from the source each time; forms change without notice.
Request for Medical Exemption From Mandatory Immunization
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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A physician (MD or DO) licensed to practice medicine in a US jurisdiction, or an advanced practice nurse licensed in a US jurisdiction. The signer attests that each contraindication or precaution is one recognized by ACIP or the AAP Red Book, ACP, AAFP or ACOG.
Yes. For each vaccine, the provider checks Temporary and enters the date through which the exemption is valid, or checks Permanent. Each vaccine also needs a valid contraindication or precaution described on page two, using the state's guide to contraindications and precautions as a reference.