North Dakota uses one certificate for a student's vaccine dates and every type of exemption for school and child care. Each vaccine row has dose dates and an exempt type: medical, history of disease, religious, or philosophical or moral. A licensed physician must sign medical and history-of-disease exemptions, while parents sign religious and personal-belief exemptions on the last page.
A physician signs that the listed doses were given and signs the medical and history-of-disease exemption statements; a physician, nurse, or local or state health official signs later updates. The parent or guardian signs religious and philosophical exemptions and the catch-up acknowledgment.
Download the current version from the source each time; forms change without notice.
Certificate of Immunization and/or Exemption
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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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No. North Dakota HHS says all exemption types are claimed on SFN 16038, and a medical exemption requires a certificate signed by a licensed physician. The physician marks the exempt type next to each affected vaccine and signs the medical exemption statement on page three.
Yes. The certificate's statement of exemption warns that in the event of an outbreak, exempted persons may be excluded from the school or child care facility. That applies to medical, history-of-disease, religious and philosophical or moral exemptions recorded on the form.