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North Carolina Department of Health and Human Services

Women’s and Children’s Health Section • Immunization Branch

Medical Exemption Statement

Physician: Please mark the true contraindications/precautions that apply to this patient, then sign and date the back of the form. The

signed Medical Exemption Statement verifying true contraindications/precautions is submitted to and accepted by schools, child care

programs and other agencies that require proof of immunization. This signed form does not require approval from the State Health

Director. For medical exemptions for conditions not listed below, the physician must submit a Physician’s Request for Medical Exemp-

tion in writing to the State Health Director for approval.

Attach a copy of the most current immunization record.

Name of Patient ___________________________________________________________ DOB ___________________

Name of Parent/Guardian _____________________________________________________________________________

Address (patient/parent) _____________________________________________________________________________

_____________________________________________________________________________

School/Child Care __________________________________________________________________________________

Medical contraindications for immunizations are determined by the most recent General Recommendations of the Advisory Committee on

Immunization Practices (ACIP), Public Health Services, U.S. Department of Health and Human Services, published in the Centers for Disease

Control and Prevention publication, the Morbidity and Mortality Weekly Report.

A contraindication is a condition in a recipient that increases the risk for a serious adverse reaction. A vaccine will not be adminis-

tered when a contraindication is present.

A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the

ability of the vaccine to produce immunity. Under normal conditions, vaccinations should be deferred when a precaution is present.

True Contraindications and True Precautions

Vaccine

General for

Contraindications

all Vaccines

Serious allergic reaction (i.e., anaphylaxis) after a previous vaccine dose: document vaccine

____________________________________________________________________________________

Serious allergic reaction (e.g., anaphylaxis) to a vaccine component: document component

____________________________________________________________________________________

Document type of reaction _______________________________________________________________

____________________________________________________________________________________

Precautions

Moderate or severe acute illness with or without fever

DTaP

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Encephalopathy within seven days after receipt of previous dose of DTP or DTaP

Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, progressive encephal-

opathy: defer DTaP until neurologic status clarified and stabilized

Precautions

Fever greater than 40.5°C (104.9°F) ≤48 hours after vaccination of previous dose of DTP or DTaP

Hypotonic-hyporesponsive episode ≤48 hours after vaccination of previous dose of DTP or DTaP

Seizure within 72 hours after vaccination of previous dose of DTP or DTaP

Persistent, inconsolable crying lasting three hours or more ≤48 hours after receiving a previous dose of

DTP or DTaP

Moderate or severe acute illness with or without fever

DT, Td

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Precautions

Guillain-Barré syndrome ≤6 weeks after a previous dose of tetanus toxoid-containing vaccine

Moderate or severe acute illness with or without fever

DHHS 3987 (Revised 3/08)

Immunization (Review 3/10)

Medical Exemption Statement - North Carolina Department Of Health And Human Services

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