Legal Exemptions to Minnesota Immunization Law

Student's Name ________________________________________

Students 7 years of age or older do not need pertussis vaccine.

Students 18 years of age or older do not need polio vaccine.

Medical exemption: No student is required to receive an immunization if they have a medical contraindication or laboratory evidence of immunity. To receive a medical exemption, a physician must sign the following statement.

I hereby certify that immunization is contraindication for medical reasons or that laboratory confirmation of adequate immunity exists for the following immunizations:

____________________________________________________________________________________

____________________________________________________ ______________________________

Signature of physician	Date

Conscientious exemption: No student is required to have an immunization, which is contrary to the conscientiously held beliefs of his/her parent or guardian. To receive this exemption, a parent or legal guardian must complete and sign the following statement and have it notarized.

I hereby certify by notarization that immunization for my child is contrary to my conscientiously held beliefs. Indicate vaccine(s):

____________________________________________________________________________________

____________________________________________________ ______________________________

Signature of parent or legal guardian	Date

Subscribed and sworn to before me this __________ day of _________________________, 20_______.

____________________________________________________________________________________

Signature of notary

Special Exceptions for DTP, Td, and Polio

Children less than 7 years of age: The 5th dose of DtaP/DTP/DT (similarly the 4th dose of polio vaccine) is not necessary if the 4th DtaP/DTP/DT (3rd dose of polio) was administered after the 4th birthday.

Children 7 years of age and older: A history of 3 doses of DtaP/DTP/Td and 3 doses of polio vaccine meets the minimum requirements of the law.

Students in grades 7 – 12: A Td booster given at age 11 or later is not required for students in grades 7 – 12 whose most recent Td was given after their 7th birthday but before their 11th birthday. Instead, it will be required 10 years after the date of the most recent dose.