Nebraska exempts a student from school or child care immunization requirements when a medical provider states that a required vaccine would be injurious to the student or to someone in the student's household. This one-page form, revised May 2023, lets the provider check each disease the student will not be immunized against, choose whose health is at risk, add comments and sign.
A physician, physician assistant or APRN nurse practitioner completes and signs the whole form. Other exemptions, such as the religious affidavit, are signed by the parent or legally authorized representative.
Download the current version from the source each time; forms change without notice.
Medical Exemptions from Vaccination Required for School Attendance in Nebraska
Medical Exemption Form - Spanish
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A physician, physician assistant or advanced practice registered nurse (nurse practitioner). The signer states that, in their professional medical opinion, immunization would be injurious to the health of the patient or of a member of the patient's household or family.
Yes. Nebraska DHHS posts a Spanish version next to the English form on its child care and school immunization page. The religious affidavit and the varicella disease documentation form are also offered in English and Spanish.