Pennsylvania's one-page school immunization card, kept on file for every student, listing dose dates for DTaP, Tdap, polio, hepatitis B, MMR, varicella, meningococcal and other vaccines. Its Statement of Exemption section is where a physician documents a medical exemption, or a parent records a religious or strong moral or ethical exemption. Schools use it to confirm compliance with the immunization rules in 28 Pa. Code Chapter 23.
A health care provider, public health official, school nurse or designee fills in or electronically produces the vaccine dates. For a medical exemption, the physician states the condition that makes immunization a danger to the child's life or health and signs with an NIP number; a parent, guardian or emancipated student signs religious or moral exemptions.
Enter the child's name, date of birth, address, parent or guardian name and telephone, circle the grade (K through 12 or Other), and mark race and Hispanic origin. The birth date is required so the school can verify that each dose was given at an appropriate age and with proper spacing.
Circle the vaccine type where offered, such as DTaP or DTP and OPV (prior to 2016) or IPV, and enter the month, day and year of each dose: DTaP, Tdap, polio, hepatitis B, MMR, varicella (vaccine or disease), meningococcal (MCV) and other. Hepatitis B and varicella rows include serology date and titer fields.
Repeat the child's name and birthdate. The section opens with a warning that during an outbreak, unvaccinated children may be excluded from school for an extended time. Only the exemption that applies is completed, and the school keeps the original signed exemption in the health record even when other records are electronic.
State the medical condition of the child that makes immunization a danger to the child's life or health, naming the specific vaccine or vaccines affected, since all others remain required. Sign with your NIP number and date. If the reason is temporary, the manual expects follow-up on when the condition allows immunization.
The parent, guardian or emancipated child states the reason for requesting the exemption based on religious beliefs, then signs and dates at the bottom of the page. The clinician does not complete this part, and a clergy member's signature is not a substitute for the parent's.
The parent, guardian or emancipated child states the strong moral, ethical or philosophical reason for the request and signs and dates the Parent or Legal Guardian Signature line at the bottom. Like the religious exemption, it does not need to be renewed each year.
Download the current version from the source each time; forms change without notice.
Pennsylvania Department of Health - Certificate of Immunization (with Statement of Exemption to Immunization Law)
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Sources for this guide
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The card's Medical Exemption line asks for the physician's signature, NIP number and date, and the Department's school manual accepts a signed statement from an MD, DO, CRNP or their designee that immunization may be detrimental to the child's health. Medical exemptions written by chiropractors, psychiatrists or dentists are not acceptable.
No. The religious and strong moral or ethical exemptions are one-time signed statements from the parent, guardian or emancipated child and do not need yearly renewal. A clergy member's signature alone is not accepted, and a signed letter from the parent can also be acceptable if it is kept in the school immunization file.
Yes. The certificate may be recorded and maintained in a school computer database, and the paper form does not have to be kept, though keeping the original is suggested in case the electronic version cannot be accessed. Electronic records must be accessible to Department staff, and any original signed exemption stays in the child's health record.