Since Public Act 21-6 repealed non-medical exemptions, a medical exemption is the only exemption Connecticut allows from required immunizations for child care, K-12 or higher education. This seven-page DPH sample lays out the information the provider enters in the DPH Medical Exemptions Submissions Portal, organized by vaccine around ACIP contraindications and precautions.
A physician (MD or DO), physician assistant or APRN completes all four parts: student demographics, contraindications or precautions by vaccine with temporary or permanent duration, an explanation if none apply, and the signed Statement of Clinical Opinion.
Download the current version from the source each time; forms change without notice.
Student Medical Exemption Certificate for Required Immunizations
Connecticut Department of Public Health, Immunization Program takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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Yes. The certificate states that its information must be entered in the Department of Public Health Medical Exemptions portal, and the PDF itself is marked as a sample. All medical exemptions issued on or after July 1, 2021 must be reported there, and the provider also gives the school a copy.
In Part 4, the clinician signs that, in accord with Public Act 21-6, the vaccines indicated are in their clinical opinion medically contraindicated for the student due to the physical condition explained on the form. The signature is dated, and the student's immunization record is attached.
No new ones. Public Act 21-6 repealed non-medical exemptions in Connecticut in 2021, leaving the medical exemption as the only exemption. A narrow transitional declaration exists for preschool students whose religious exemption predates April 28, 2021.