December 22, 2021 – Commissioner’s order: Out of state licensed providers should read this memo from DPH Commissioner Manisha Juthani, MD and note the list of professions authorized by the Commissioner’s order

Immunizations Exemptions Certification Forms

Immunization exemptions are permitted under certain circumstances.  According to state law, a child can be exempted from receiving a vaccine for medical conditions which are contraindicated.  If this circumstance is true for your child, please read the form below for additional information. Should you need to use an exemption form, please print the form below, complete it, and return it to your school nurse or daycare operator.

If you are using one of the translated forms, please also print the English version.

Medical Exemption Form English April, 2011

Medical Exemption Form Spanish June 2011

Medical Exemption Form Polish June 2011

Medical Exemption Form Brazilian Portuguese June 2011

Medical Exemption Form Haitian Creole June 2011

Medical Exemption Form Traditional Chinese June 2011





For more information or to contact the Immunization Program, please call:
860-509-7929, during normal business hours, Monday-Friday 8:30am to 4:30pm


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