Indiana students who qualify for a medical exemption from school immunization requirements need this Indiana Department of Health form, which IDOH says the student's health care provider should fill out. The school receives the completed form and records the exemption in CHIRP, the Children and Hoosiers Immunization Registry Program.
The student's health care provider (physician) completes the whole form to certify the medical exemption.
Download the current version from the source each time; forms change without notice.
Vaccine Medical Exemption Form
Vaccine Medical Exemption Form (Spanish)
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IDOH says a student's health care provider should fill out the form for the student to qualify for a medical exemption. The completed form goes to the school, and school staff then record the exemption in CHIRP, Indiana's immunization registry.
Yes. IDOH links both an English version and a Spanish version, each hosted on Indiana's state forms website. Both are listed on IDOH's page for school administrators and nurses, next to its guidance on entering exemptions in CHIRP.
School staff enter it in CHIRP, the Children and Hoosiers Immunization Registry Program, after receiving the provider-completed form. IDOH publishes a video, How to Enter an Exemption in CHIRP, plus CHIRP school module report descriptions and FAQs for school nurses.