State-by-State Exemption Database
Documentation requirements, approval authority, and exemption types across all 50 states and the District of Columbia
Overview
Every U.S. state and the District of Columbia requires certain vaccinations for school entry, but the types of exemptions available and the procedures for obtaining them vary significantly by jurisdiction, according to the National Conference of State Legislatures (NCSL) and individual state statutes.
All 51 jurisdictions permit medical exemptions. Forty-four states and the District of Columbia permit religious exemptions, while six states do not. Fifteen states permit philosophical or personal belief exemptions, and Washington permits them for all required vaccines except MMR (measles, mumps, and rubella).
Note: Of the six states that do not permit religious exemptions, five do so by statute (California, Connecticut, Maine, New York, and West Virginia). Mississippi's statute authorizes only medical exemptions, but a federal court ordered the Mississippi State Department of Health to create a religious exemption process in Bosarge v. Edney (S.D. Miss., April 18, 2023). That process is now operational but has not been codified in statute.
This page presents the documentation requirements, approval authority, and procedural details for each jurisdiction in a single reference table. The data is drawn from state statutes, administrative codes (state agency rules that help implement statutes), state health department forms and guidance, NCSL, and Immunize.org. Items that could not be confirmed against a primary source are marked as unverified.
How to Read This Table
Medical Exemption column: Identifies who can sign or certify a medical exemption (such as an MD, DO, nurse practitioner, physician assistant, or other authorized provider), whether a standardized state form is required, and whether the state health department reviews or approves exemptions.
Religious Exemption column: Describes the documentation required (such as a signed statement, notarized affidavit, or state form), whether a sincerity review (review of whether a claimed religious belief is sincerely held) is conducted, and whether annual renewal is required. States that do not permit religious exemptions are marked accordingly.
Philosophical / Personal Belief Exemption column: Shows the statutory term used (personal belief, conscience, philosophical, nonmedical, etc.), documentation requirements, and renewal rules. States that do not permit philosophical exemptions are marked accordingly.
Primary Statute column: Cites the principal state statute or administrative code governing school immunization exemptions.
Highlighted rows: Amber rows indicate jurisdictions with active litigation or court-ordered exemption processes (Mississippi and West Virginia). Blue rows indicate partial exemption status (Washington, where philosophical exemption is not permitted for MMR only).
51-Jurisdiction Exemption Database
Note: Terminology varies by state. A state may use labels such as "religious," "personal belief," "conscience," "conscientiously held belief," or "nonmedical" for similar exemption categories.
| State | Medical Exemption | Religious Exemption | Philosophical / Personal Belief Exemption | Primary Statute |
|---|---|---|---|---|
| Alabama | MD/DO; Form IMM-51; County HD issues via ImmPRINT | Written statement via county HD after education session; Form IMM-52; no sincerity review; no renewal | Not permitted | Ala. Code 16-30-3 |
| Alaska | MD/DO/ANP/PA; State form; No state review | Notarized affidavit on state form; annual renewal | Not permitted | AS 14.30.125 |
| Arizona | MD/DO/RNP; ADHS form; No state review | K-12 handled under personal beliefs provision; signed statement | Personal beliefs; signed statement; no education; no renewal | A.R.S. 15-873 |
| Arkansas | Licensed physician; ADH online application; ADH reviews | Notarized statement + education module; annual renewal | Philosophical; same ADH application; notarized; education required; annual renewal | Ark. Code 6-18-702 |
| California | MD/DO only; CAIR-ME electronic form; CDPH review (schools below 95%, providers issuing 5+ per year) | Not permitted (SB 277, 2015) | Not permitted (SB 277, 2015) | Cal. H&S Code 120370-120375 |
| Colorado | MD/DO, PA, APN; CDPHE Certificate; No review | Merged into nonmedical exemption | Nonmedical; CDPHE online module OR provider signature; annual renewal (K-12) | C.R.S. 25-4-902, 25-4-903 |
| Connecticut | MD/DO, PA, APRN; DPH Certificate; DPH portal submission | Not permitted; grandfather for pre-4/28/2021 exemptions | Not permitted | Conn. Gen. Stat. 10-204a (PA 21-6) |
| Delaware | MD/DO (NP/APRN accepted in practice); DPH form; DPH approval | Notarized Affidavit of Religious Belief | Not permitted | 14 Del. C. 131 |
| District of Columbia | MD/DO or NP; DC Universal Health Certificate | Good-faith written objection to public health authorities | Not permitted | D.C. Code 38-506 |
| Florida | MD/DO (permanent); MD/DO/DC (temporary); Form DH 680; No review | Form DH 681 from county HD; no questions; no sincerity review; no renewal | Not permitted | Fla. Stat. 1003.22(5) |
| Georgia | MD/DO, APRN, PA, or HD staff; DPH Form 3231; No review | Notarized Affidavit of Religious Objection (Form 2208); no sincerity review; no renewal | Not permitted | O.C.G.A. 20-2-771 |
| Hawaii | MD/DO, PA, APRN; State form; No review | Written objection based on bona fide religious tenets | Not permitted | HRS 302A-1156 |
| Idaho | Physician; State form optional; No review | Signed parent statement on religious or other grounds; no review; no renewal | Religious or other grounds (combined); signed statement; no education; no renewal | Idaho Code 39-4802 |
| Illinois | MD/DO, APRN, or PA; IDPH Certificate; No pre-approval | State Certificate of Religious Exemption (2015); co-signed by provider; renewal at K/6th/9th | Not permitted | 105 ILCS 5/27-8.1 |
| Indiana | MD/DO, NP, PA; IDOH form in CHIRP; No review | Parent signed written statement; no form; no sincerity review; annual renewal (IDOH guidance) | Not permitted | Ind. Code 20-34-3-2 |
| Iowa | MD/DO, NP, PA; HHS Medical Certificate; No review | HHS Religious Certificate; notarized and signed; no renewal | Not permitted (expressly excluded) | Iowa Code 139A.8 |
| Kansas | MD/DO only; KCI Form B; No review; annual physician statement | Signed parent statement; no state form; no sincerity review; no renewal | Not permitted | K.S.A. 72-6262 |
| Kentucky | MD/DO, APRN, PA, pharmacist, LHD admin, RN, LPN; Form EPID 230; No review | Notarized sworn statement or Form EPID 230A; no sincerity review; no renewal | Not permitted for K-12 (conscience applies only to epidemic mandates) | KRS 214.036 |
| Louisiana | Physician; No mandated form; No review | Written dissent; no notarization; all requests granted; no renewal | Written dissent (covers religious, philosophical, personal, conscientious); no education; no renewal | LSA-R.S. 17:170(E) |
| Maine | MD/DO, NP, PA; No mandatory state form; No review | Not permitted (LD 798 / PL 2019 ch. 154, effective 9/1/2021); narrow IEP grandfather | Not permitted | 20-A MRSA 6355, 6359 |
| Maryland | Medical provider (not narrowly specified); MDH Form 896; No formal review | MDH Form 896 religious section; bona fide religious beliefs; no notarization; no sincerity review | Not permitted | Md. Code Educ. 7-403; COMAR 10.06.04 |
| Massachusetts | Physician certificate; No standardized form; No review | Written statement that vaccination conflicts with sincere religious beliefs; no form; no notary; no renewal | Not permitted | MGL ch. 76, 15 |
| Michigan | Physician; MDHHS Medical Contraindication form; No review for medical | Parent statement on MDHHS waiver; in-person LHD education session; renewal at grade transitions | Other objection; same MDHHS waiver; in-person LHD education required; renewal at grade transitions | MCL 333.9215 |
| Minnesota | Physician; MDH form; Notarized statements forwarded to MDH | Encompassed in conscientiously held beliefs (see philosophical) | Conscientiously held beliefs; notarized statement; no mandatory education; no annual renewal | Minn. Stat. 121A.15 |
| Mississippi | MS-licensed MD/DO only; Form 139-M; State Epidemiologist reviews; listed contraindications only | Permitted since April 2023 (Bosarge v. Edney injunction); Form 139-R; county HD appointment + education video; no renewal | Not permitted | Miss. Code 41-23-37 |
| Missouri | MD/DO; DHSS Form Imm.P.12; No pre-approval | DHSS Form Imm.P.11A (mandatory per Baker v. Crossroads, 2023); no sincerity review; no renewal | Not permitted K-12; permitted for daycare via Form Imm.P.11 | RSMo 167.181; 210.003 |
| Montana | Any qualifying provider licensed in US/Canada; Form HES-101; Review expressly prohibited by statute | DPHHS Form HES-113 affidavit; traditionally notarized; no sincerity review | Not permitted | MCA 20-5-405 |
| Nebraska | MD/DO, PA, APRN; No mandatory form; No review | Affidavit signed by parent; commonly notarized; no state sincerity review; no renewal | Not permitted | Neb. Rev. Stat. 79-221 |
| Nevada | Licensed physician; DPBH state form; Local HD may audit; No cap | DPBH state form; no sincerity review; annual renewal required | Not permitted | NRS 392.437, 392.439 |
| New Hampshire | Physician; DHHS form optional; No review | Parent-signed written statement; no notarization (since HB1035, 2022); no sincerity review; no renewal | Not permitted | RSA 141-C:20-c |
| New Jersey | MD/DO, CRNP, CNS; No mandated form; Medical must match ACIP/AAP | Signed parent statement that immunization interferes with religious rights; no sincerity review; no notarization; no renewal | Not permitted | N.J.S.A. 26:1A-9.1; N.J.A.C. 8:57-4.4 |
| New Mexico | MD/DO, PA, CNP (2023 amendment); NMDOH Certificate; Dept of Health approval required | Officer of recognized denomination OR parent notarized affidavit; sincerity review by NMDOH; 9-month validity | Not permitted | NMSA 24-5-3 |
| New York | NY-licensed physician only; Written certification with ACIP rationale; NYC DOH/school review; annual resubmission | Not permitted (Ch. 35 of Laws of 2019) | Not permitted | N.Y. Pub. Health Law 2164 |
| North Carolina | NC-licensed MD/DO only; Form DHHS 3987; Conditional review for non-listed contraindications | Written statement of bona fide religious beliefs; no state form; no sincerity review; no renewal | Not permitted | N.C. Gen. Stat. 130A-156, 130A-157 |
| North Dakota | Licensed physician only; NDDoH form; No review | Combined beliefs exemption (see philosophical) | Religious, philosophical, or moral beliefs; parent-signed certificate; no notarization; no education | N.D.C.C. 23-07-17.1 |
| Ohio | Physician (MD/DO); No mandated form; No review | Reasons of conscience, including religious convictions (combined); signed parent statement; no sincerity review | Reasons of conscience; same provision as religious; no education required | Ohio Rev. Code 3313.671(B) |
| Oklahoma | Licensed physician; OSDH Certificate; OSDH reviews (1-3 days) | OSDH Certificate; signed by leader or parent; mandatory county HD presentation; renewal before 7th grade | Personal; OSDH Certificate; mandatory county HD presentation; renewal before 7th grade | 70 Okl. St. 1210.192 |
| Oregon | Physician; CIS form or letter; No review | Merged into nonmedical exemption | Nonmedical; Vaccine Education Certificate + CIS; must complete OHA online module OR practitioner signature; no renewal | ORS 433.267 |
| Pennsylvania | Physician or designee; No mandated form; No review | Written objection by parent; no form; no notary; no sincerity review; no renewal | Strong moral or ethical conviction similar to a religious belief; written objection only; no education; no renewal | 28 Pa. Code 23.84 |
| Rhode Island | MD, PA, CRNP, or other licensed practitioner; RI DOH Certificate; No review | RI DOH Religious Exemption Certificate; parent signs; acknowledges educational materials; no sincerity review | Not permitted | R.I. Gen. Laws 16-38-2 |
| South Carolina | Licensed MD/DO or representative; SC Certificate; No review | Notarized Statement of Religious Objection via DPH; no sincerity review; no renewal | Not permitted | S.C. Code 44-29-180 |
| South Dakota | MD/DO only; SDDoH Certificate; No review | Signed parent statement; no notarization; no sincerity review; no renewal | Not permitted | SDCL 13-28-7.1 |
| Tennessee | Qualified physician; State Immunization Certificate; No state review | Signed written statement affirmed under penalty of perjury; no notarization; no clergy; no sincerity review | Not permitted | T.C.A. 49-6-5001 |
| Texas | Examining physician (MD/DO); No mandated form; Valid 1 year | Same mechanism as philosophical (see philosophical) | Reasons of conscience, including a religious belief; DSHS Affidavit Form; notarized; valid 2 years; no sincerity review | Tex. H&S Code 161.004 |
| Utah | Licensed provider (MD/DO/APRN/PA); State-issued form from DHHS; No review | Same personal exemption category as philosophical | Personal exemption; state form; must complete online education module OR in-person LHD consultation; no renewal (HB 228, 2025: one-time K-12 opt-out) | Utah Code 53G-9-303 |
| Vermont | Licensed practitioner authorized to prescribe vaccines; VDH Medical Exemption form; No review | Parent-signed statement on VDH form; must attest to review of educational materials; no sincerity review; annual renewal | Not permitted (Act 37, 2015, effective 7/1/2016) | 18 V.S.A. 1122 |
| Virginia | Licensed physician, APRN, or local HD; Form MCH213G Part III; No review | Notarized Certificate of Religious Exemption (Form CRE-1); no sincerity review; no renewal; inapplicable during declared outbreak | Not permitted | Va. Code 22.1-271.2, 32.1-46 |
| Washington | MD/DO/ND/PA/ARNP; WA DOH Certificate of Exemption; No review | COE signed by parent + practitioner signature attesting info provided; separate Religious Membership sub-type; no sincerity review; no renewal | Personal/philosophical objection; NOT permitted for MMR (HB 1638, 2019); practitioner signature required; no renewal | RCW 28A.210.090 |
| West Virginia | Licensed physician (MD/DO); Submission to State Immunization Officer; Commissioner reviews | Not permitted by statute; 2025 executive order stayed by WV Supreme Court (Dec. 2, 2025); active litigation | Not permitted | W.Va. Code 16-3-4 |
| Wisconsin | Physician (MD/DO); DHS Form F-04020L; No review | Written signed statement on DHS form; no notary; no clergy; no sincerity review; no renewal | Personal conviction; same DHS form and signed statement; no education; no renewal | Wis. Stat. 252.04 |
| Wyoming | Provider-documented evidence; WDH Medical Waiver form; State/County Health Officer authorizes | WDH Religious Waiver form; submitted to Health Officer; no sincerity inquiry (LePage v. State, 2001); no renewal | Not permitted | Wyo. Stat. 21-4-309 |
Note: Some data points regarding nurse practitioner or physician assistant signature authority, annual renewal timing, and recent legislative changes could not be confirmed against primary sources within the research scope. These items are marked as unverified in the detailed research report. For policy decisions, consult the relevant state statute and current state health department guidance directly.
Key Patterns Across Jurisdictions
Medical Exemption Signature Authority
The majority of states authorize physicians (MD or DO) to sign medical exemptions. A growing number also authorize nurse practitioners and physician assistants. New York, Kansas, South Dakota, and North Dakota restrict medical exemptions to physicians only. Kentucky authorizes a wider range of signers, including pharmacists, local health department administrators, and designated nurses. Washington is the only state in this table that expressly authorizes naturopaths (NDs) to sign medical exemptions, according to RCW 28A.210.090.
State Review of Medical Exemptions
Active state review of medical exemptions exists in California, New Mexico, Wyoming, Arkansas, Oklahoma, West Virginia, Mississippi, Alabama, Delaware, Connecticut, New York, and North Carolina (for non-listed contraindications), according to individual state statutes. California's SB 276 framework — which flags providers issuing five or more exemptions per calendar year or schools with vaccination rates below 95% — represents one of the most detailed auditing systems. Montana uniquely prohibits state review of medical exemption statements by statute (MCA 20-5-405(3)(c)), according to the Montana Code Annotated.
Religious Exemption Documentation Categories
Religious exemption documentation requirements fall into four general categories across states that permit them, according to state statutes and health department guidance:
Category 1 — Signed parental statement only: New Hampshire, Massachusetts, Pennsylvania, Ohio, Wisconsin, Indiana, North Carolina, South Dakota, and Tennessee.
Category 2 — Notarized affidavit: Alaska, Delaware, Georgia, Iowa, Kentucky, South Carolina, Virginia, and Minnesota.
Category 3 — Mandatory education session or module: Oregon, Utah, Michigan (in-person), Oklahoma, Mississippi, Colorado, Washington (practitioner signature), Illinois (practitioner co-signature), Arkansas, and Vermont.
Category 4 — State approval with possible denial: New Mexico, Wyoming, Arkansas, and Oklahoma.
Common Structures for Philosophical Exemptions
Three structural approaches exist among the 15 states and Washington that permit philosophical exemptions, according to NCSL and state statutes:
First, a standalone philosophical category alongside a separate religious exemption: Arizona, Arkansas, Michigan, Minnesota, Wisconsin, and Washington (for non-MMR vaccines).
Second, a merged nonmedical or conscience category encompassing both religious and philosophical grounds under one provision: Colorado, North Dakota, Ohio, Oregon, Pennsylvania, Texas, Utah, Louisiana, and Idaho.
Third, states that do not permit philosophical exemptions: all remaining jurisdictions.
Annual Renewal Requirements
Mandatory periodic renewal of religious or nonmedical exemptions is required in Alaska, Arkansas, Colorado (K-12), Nevada, New Mexico (9-month/school-year validity), Vermont, and New York (for medical exemptions), according to individual state statutes and health department guidance. Texas requires renewal every two years. Most other states treat the exemption as continuing during enrollment.
Notable 2023-2026 Developments
Mississippi: A federal court ordered the Mississippi State Department of Health to create a religious exemption process in Bosarge v. Edney (S.D. Miss., April 18, 2023). The exemption is now operating through Mississippi State Department of Health procedures but has not been codified in statute, according to MSDH and court filings.
West Virginia: The governor issued Executive Order 7-25 (January 2025) recognizing religious exemptions, but the West Virginia Supreme Court stayed a favorable lower-court ruling on December 2, 2025, according to West Virginia Watch. The statute (W.Va. Code 16-3-4) continues to authorize only medical exemptions. SB 460 (2025), which would have added religious and philosophical exemptions, was rejected by the House 42-56 on March 24, 2025.
Idaho: HB 307 (2024) added a provision allowing adult students (age 18+) to self-submit exemption forms without a parent signature, according to Idaho Code 39-4802(4).
Utah: HB 228 (2025) removed exemption expiration dates, barred school processing fees, and made exemptions a one-time K-12 opt-out rather than requiring periodic renewal, according to Utah Code 53G-9-303.
Texas: HB 1586 (2025, effective September 1, 2025) required DSHS to post downloadable blank affidavit forms and eliminated name-tracking requirements, according to Tex. Health and Safety Code 161.0041.
North Dakota: HB 1454 (2025) created a broad opt-out framework across state agencies, while preserving the existing school exemption structure under N.D.C.C. 23-07-17.1.
New Mexico: A 2023 amendment (Laws 2023, ch. 94) added physician assistants and certified nurse practitioners as authorized signers for medical exemptions, according to NMSA 24-5-3.
D.C.: Law 25-108 (2023, effective January 23, 2024) added nurse practitioners as authorized medical exemption signers and restructured the religious objection submission process to route through public health authorities, according to D.C. Code 38-506.
Sources and Citations
Government and Institutional Sources
- National Conference of State Legislatures (NCSL). "States With Religious and Philosophical Exemptions From School Immunization Requirements." Updated January 2025. ncsl.org/health/states-with-religious-and-philosophical-exemptions-from-school-immunization-requirements
- Immunize.org. "Exemptions Permitted for State Childcare and School (K-12) Immunization Requirements 2025." immunize.org/official-guidance/state-policies/vaccine-requirements/exemptions-child-school-2025/
- CDC. "State School Immunization Requirements and Vaccine Exemption Laws." cdc.gov/phlp/docs/school-vaccinations.pdf
- Justia. "School Immunization Exemption Laws: 50-State Survey." justia.com/education/school-immunization-exemption-laws-50-state-survey/
- Individual state statutes, administrative codes, and health department websites (cited per jurisdiction in the table).
Case Law
- Bosarge v. Edney, 669 F Supp.3d 598 (S.D. Miss. 2023)
- Brown v. Smith, 24 Cal.App.5th 1135 (Cal. Ct. App. 2018)
- Phillips v. City of New York, 775 F.3d 538 (2d Cir. 2015)
- We The Patriots USA, Inc. v. Connecticut Office of Early Childhood Development (2d Cir. 2023)
- LePage v. State, 18 P.3d 1177 (Wyo. 2001)
- Jones v. State, 18 P.3d 1189 (Wyo. 2001)
- Baker v. Crossroads Academy (Mo. Ct. App. W.D. 2023)