How to Fill Out the Connecticut Student Medical Exemption Certificate for Immunizations

Connecticut’s Student Medical Exemption Certificate for Immunizations is the state-issued form a licensed physician, physician assistant, or advanced practice registered nurse fills out to exempt a child from one or more required school vaccines on medical grounds. You download it from the Connecticut Department of Public Health, bring it to the appointment, and after the provider completes and signs it, you deliver it to the child’s school nurse along with the child’s current immunization record.¹

Who Can Sign the Form

Only a Connecticut-licensed physician (MD or DO), physician assistant, or advanced practice registered nurse can certify a medical exemption. Connecticut General Statutes § 10-204a requires the provider to attest that the immunization is “medically contraindicated because of the physical condition of such child.”² The exemption is vaccine-by-vaccine. A provider cannot write one blanket exemption for every shot; each vaccine the child needs to skip gets its own clinical reason on the form.

Before the Appointment

Download the certificate from the DPH immunization laws and regulations page, or ask the school nurse for a copy.¹ Bring the child’s complete immunization record with you. The statute requires the provider to attach that record to the certificate, and schools may not accept the form without it.³

You can fill out Part 1 ahead of time. The rest belongs to the provider.

Part 1: Student and Parent Information

Part 1 is the only section a parent completes. You enter the child’s full first name, middle initial, last name, and date of birth, plus a mailing address. Add your own name as parent or guardian and a primary phone number. Then write the school name, school address, and the grade the child is in or entering.⁴

Match the school name exactly to the institution the child actually attends. The certificate follows the student to that specific school, so a mismatch creates confusion when the nurse tries to log it.

Part 2: Vaccines and CDC Contraindications

Part 2 is where the provider identifies each vaccine being exempted. For every one, they check the vaccine name, mark whether the exemption is temporary or permanent, and select which CDC-recognized contraindication or precaution applies from the list printed on the form. A temporary exemption also needs a month and year when it expires.⁴

The CDC-recognized reasons mirror the federal contraindication and precaution tables. The most common one across nearly all vaccines is a severe allergic reaction (anaphylaxis) after a previous dose or to a vaccine component.⁵ Beyond that, each vaccine has its own list. DTaP, for example, includes encephalopathy within seven days of a previous dose, progressive neurologic disorders such as uncontrolled epilepsy, or Guillain-Barré syndrome within six weeks of a prior tetanus-containing vaccine. MMR and varicella include known severe immunodeficiency or pregnancy. Hepatitis B includes hypersensitivity to yeast. Live attenuated influenza vaccine includes concurrent aspirin use in children, asthma diagnosis in young children, or altered immunocompetence.

Precautions are weaker than contraindications. A moderate or severe acute illness is a precaution for most vaccines, which usually means waiting until the child recovers rather than skipping the vaccine for good. In that case the provider would mark a temporary exemption with an expected recovery date.

Part 3: Non-CDC Reasons

If the child’s situation does not match any contraindication or precaution on Part 2, the provider uses Part 3 to write a short explanation of why the vaccine is medically contraindicated for this child. Connecticut General Statutes § 19a-7q specifically identifies autoimmune disorders, a family history of autoimmune disorders, a family history of vaccine reactions, a genetic predisposition to vaccine reactions confirmed through genetic testing, and a previous documented reaction correlated to a vaccination as valid non-CDC grounds.³ The statute leaves clinical judgment with the provider in this section.

For each exempted vaccine, either a Part 2 box or a Part 3 explanation needs to be filled in. A vaccine marked as exempted with nothing checked and nothing written is incomplete.

Provider Signature and Attachments

The provider signs and dates the certificate, indicates their practitioner type (MD, DO, PA, or APRN), and enters their Connecticut license number, National Provider Identifier, practice name, office address, and phone number.⁴ They attach the child’s most current immunization record, which the statute requires.³

Before you leave the office, glance at the signature line, the date, the license number, and the NPI. These are the fields most often left blank.

Where to Submit It

Deliver the signed certificate and the attached immunization record directly to your child’s school. The school nurse is usually the right recipient, though some districts route the form through a central administrative office. The school reviews the form for completeness and enters the exemption into the state’s immunization registry, which tracks the child’s vaccination status across schools and grade levels.¹

Common Mistakes That Get the Form Sent Back

A few errors come up repeatedly:

No provider signature or date. An unsigned certificate has no legal effect, and the school cannot enter it into the registry.
Missing Connecticut license number or NPI.
A vaccine checked as exempted with no contraindication marked on Part 2 and no written reason on Part 3.
A temporary exemption with no expiration month and year filled in.
No immunization record attached.
School name on Part 1 that doesn’t match the child’s actual school.

Catching these in the office saves a return trip.

Keeping the Exemption Valid Over Time

If the provider marked the exemption as temporary, the school tracks the expiration date. Once that date passes, the child either gets the vaccine or submits an updated certificate extending or converting the exemption. A lapsed temporary exemption can result in the student being excluded from school until the family resolves it.²

Students generally need an updated certificate when they move between school levels, such as elementary to middle school. Some districts also run periodic reviews to confirm the condition still exists. If the child changes schools within the same district, check with the new school nurse about whether the existing certificate transfers.

One more thing worth knowing: even with a valid medical exemption on file, a child who is unvaccinated or undervaccinated may be kept home during an outbreak of a vaccine-preventable disease at the school. The exclusion typically lasts for the duration of the outbreak.

A Note on Religious Exemptions

Medical exemption is now the only path to new exemptions in Connecticut. Public Act 21-6 ended religious exemptions for new filers but grandfathered K–12 students who already had a notarized religious exemption on file before the law took effect.⁶ If you did not have a religious exemption in place before then, this certificate is the only route available.

1
Connecticut Department of Public Health. Immunization Laws and Regulations
2
Justia. Connecticut Code 10-204a – Required Immunizations. Temporary Waiver
3
Justia. Connecticut Code 19a-7q
4
Connecticut State Department of Education. Student Medical Exemption Certificate for Required Immunizations
5
CDC. Contraindications and Precautions
6
Connecticut General Assembly. Public Act No. 21-6