Background: Children are required by law to receive vaccinations to enter school. States and territories offer exemptions for parents who refuse to vaccinate their children. Types of exemptions vary by state or territory, as does the exemption claiming process. The purpose of this research was to identify the various education-related processes implemented by states and territories which allow parents to exempt children from vaccinations. Methods: A questionnaire was distributed to immunization managers in the 50 United States, District of Columbia, the United States Indian Health Service, and eight United States territories. Managers reported vaccination requirements for their jurisdiction (collectively referred to as "state"). Education-related questions, identified which states required parents to: 1) read and sign a vaccination risk/benefit statement prior to exemption; 2) complete mandatory vaccine education before obtaining vaccination exemption; 2a) complete education within a certain time period before school admission; and 2b) have parental vaccine education regulated. Results: A parent-signed risk/benefit statement was required by 25 states for religious exemptions, 12 states for personal exemptions, 10 states for medical exemptions, and 1 state for temporary medical exemptions. Thirteen states required mandatory parental vaccine education prior to obtaining an exemption. Vaccine education could be completed at various times prior to school admission. For most states, the mandated parental vaccine education prior to exemption was regulated by law, administrative rule, or policy. Conclusions: Implementing a risks/benefits statement prior to granting an exemption may not be helpful in reducing religious and personal exemption rates. The process of providing vaccine education prior to exemption varies greatly between states. Familiarity with various state vaccine education requirements may aid policymakers who are considering enacting mandatory vaccine education in his or her state.



College and Department

Nursing; Nursing



Date Submitted


Document Type





vaccination, exemption, immunization, state requirements, education



Included in

Nursing Commons