Nonmedical Exemption Form

Immunization
Certificate of Nonmedical Exemption

Colorado law C.R.S. § 25-4-902 requires all students attending any school in the state of Colorado to be vaccinated against certain
vaccine-preventable diseases, as established by Colorado Board of Health rule 6 CCR 1009-2, unless an exemption is filed. This law
applies to students attending public, private and parochial kindergarten, elementary and secondary schools through 12th grade,
colleges or universities, and child care facilities licensed by the Colorado Department of Human Services including child care
centers, school-age child care centers, preschools, day camps, resident camps, day treatment centers, family child care homes,
foster care homes, and Head Start programs. “Nonmedical exemption” means an immunization exemption based upon a religious
belief whose teachings are opposed to immunizations or a personal belief that is opposed to immunizations. Prior to kindergarten, a
nonmedical exemption must be filed each time a student is due for vaccines according to the schedule developed by the ACIP. 1,2
From kindergarten through 12th grade, a nonmedical exemption must be filed every year during the student’s school enrollment/
registration process.1 Students with a recorded immunization exemption may be kept out of a child care facility or school during a
disease outbreak; the length of time will vary depending on the type of the disease and the circumstances of the outbreak.
Please complete all required fields below and obtain all required signatures; incomplete forms will not be accepted.
Student Information:
Last Name: First Name: Middle Name:
Date of Birth: Sex: ☐ Female ☐ Male ☐X
Parent/Guardian Completing This Form: ☐ Check if an emancipated student or student over 18 years old
Last Name: First Name: Middle Name:
Relationship to student: ☐ Mother ☐ Father ☐ Legal Guardian
School/Licensed Child Care Facility Information:
School Name/Licensed Child Care Facility:
School District: ☐ Check if Not Applicable
Address:
City: State: Zip Code:
Required Vaccines for School Entry - Place an “X” next to each vaccine for which you are claiming a nonmedical exemption.
Diphtheria, tetanus, pertussis (DTaP) Inactivated poliovirus (IPV)
Tetanus, diphtheria, pertussis (Tdap) Measles, mumps, rubella (MMR)
Haemophilus influenzae type b (Hib) Pneumococcal conjugate (PCV13)
Hepatitis B Varicella (chickenpox)
Statement of Exemption
I am the parent/guardian of the above-named student or am the student themself (emancipated or over 18 years of age) and am
claiming a nonmedical exemption from the vaccine(s) indicated above. The information I have provided on this form is complete and
accurate. I can review evidence-based vaccine information at www.colorado.gov/cdphe/immunization-education,
www.spreadthevaxfacts.com/, www.ImmunizeForGood.com/ for additional information on the benefits and risks of vaccines and the
diseases they prevent. I can contact the Colorado Immunization Information System (CIIS) at www.covaxrecords.org or my health care
provider to locate my child’s/my immunization record. 3
REQUIRED Signature: Date: ___________

Parent/Legal Guardian/Student (emancipated or over 18 years old)
REQUIRED Provider Signature Section:

REQUIRED Print Name, Title, and Signature:___________________________________________________________ Date: ____________
Physician (MD, DO), Advanced Practice Nurse (APN), Physician Assistant, Registered Nurse (RN) or Pharmacist (authorized pursuant to section 12-240-107 (6), C.R.S.)
REQUIRED Colorado Professional License Number: __________________
-- OR --
Online Education Module Completion Date and Time (system generated):___________________________________________________
*A certificate of nonmedical exemption generated from the department's online education module is only complete and valid if both the system-generated date and timestamp and CDPHE
watermark are present.
1
Colorado Board of Health rule 6 CCR 1009-2: https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=7698&fileName=6%20CCR%201009-2
2
2021 Recommended Immunizations from Birth through 6 Years Old: www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf. Based on this schedule, a nonmedical exemption
would be submitted at 2 months, 4 months, 6 months, 12 months and 18 months of age.
3
Under Colorado law, you have the option to exclude your child’s/your information from CIIS at any time. To opt out of CIIS, go to www.colorado.gov/cdphe/ciis-opt- out-procedures.
Please be advised you will be responsible for maintaining your child’s/your immunization records to ensure school compliance.
Last Reviewed August 2021

Nonmedical Exemption Form

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Nonmedical Exemption Form

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Immunization

Certificate of Nonmedical Exemption

REQUIRED Signature: Date: ___________

REQUIRED Provider Signature Section:

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