Vaccines are one of the greatest public health achievements of the past century and save an estimated 3 million children's lives every year. The Colorado Department of Public Health and Environment strongly supports vaccination as one of the easiest and most effective tools in preventing diseases that can cause serious illness and even death. For nearly all children, the benefits of preventing disease with a vaccine far outweigh the risks. Colorado law C.R.S. § 25-4-902 requires all students attending any school in the state of Colorado to be vaccinated against certain vaccine-preventable diseases as established by Colorado Board of Health rule 6 CCR 1009-2, unless an official exemption form is filed.
This law applies to students attending child care facilities licensed by the Colorado Department of Human Services, public, private and parochial kindergarten, elementary and secondary schools through 12th grade, and colleges or universities. Prior to kindergarten, an official non-medical exemption form must be filed each time a student is due for vaccines according to the schedule developed by the Advisory Committee on Immunization Practices.1,2 From kindergarten through 12th grade, an official non-medical exemption form must be filed every year during the student’s school enrollment/registration process1 . Students with an immunization exemption may be kept out of a child care facility or school during a disease outbreak; the length of time will vary depending on the type of disease and the circumstances of the outbreak.
Please complete all required fields below; incomplete forms will not be accepted. All fields are required unless noted optional.
Parent/Guardian Completing This Form
School/Licensed Child Care Facility Information
Required Vaccines for Entering School
The information below is provided to ensure parents/guardians/students are informed about the risks of not vaccinating.
Initial each vaccine declined
Hepatitis B - My child/I may be at increased risk of developing hepatitis B if exposed to this disease. Serious symptoms and effects include jaundice, life-long liver problems such as liver damage, scarring, liver cancer, and death. For more information: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.pdf
Diphtheria, tetanus, pertussis (DTaP, Tdap) - My child/I may be at increased risk of developing diphtheria, tetanus and/or pertussis if exposed to these diseases. Serious symptoms and effects of diphtheria include heart failure, paralysis, breathing problems, coma, and death. Serious symptoms and effects of tetanus include “locking” of the jaw, difficulty swallowing and breathing, seizures, painful tightening of muscles in the head and neck, and death. Serious symptoms and effects of pertussis (whooping cough) include severe coughing fits that can cause vomiting and exhaustion, pneumonia, seizures, brain damage, and death. For more information: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/dtap.pdf and http://www.cdc.gov/vaccines/hcp/vis/visstatements/tdap.pdf
Haemophilus influenza type b (Hib) – My child/I may be at increased risk of developing invasive Hib disease if exposed to this disease. Serious symptoms and effects include bacterial meningitis, pneumonia, severe swelling in the throat, permanent neurologic damage including blindness, deafness, and mental retardation, infections of the blood, joints, bones, and covering of the heart, and death. For more information: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hib.pdf
Inactivated poliovirus (IPV) – My child/I may be at increased risk of developing polio if exposed to this disease. Serious symptoms and effects include paralysis of muscles that control breathing, meningitis, permanent disability, and death. For more information: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/ipv.pdf
Measles-mumps-rubella (MMR) - My child/I may be at increased risk of developing measles, mumps, and/or rubella if exposed to these diseases. Serious symptoms and effects of measles include pneumonia, seizures, brain damage, and death. Serious symptoms and effects of mumps include meningitis, painful swelling of the testicles or ovaries, sterility, deafness, and death. Serious symptoms and effects of rubella include rash, arthritis, and muscle or joint pain. If a pregnant woman gets rubella, she could have a miscarriage or her baby could be born with serious birth defects such as deafness, heart problems, and mental retardation. For more information: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.pdf
I am the parent/guardian of the above-named student or am the student himself/herself (emancipated or over 18 years of age) and have a religious or personal belief that is opposed to vaccines. By signing this form, I am declining the vaccine(s) required for school entry for my child/myself, as initialed above, and understand the following:
My child/I may not be able to attend child care or school during a disease outbreak.
Some vaccine-preventable diseases are common in other countries and my child/I could easily get one of these diseases while traveling or from a traveler.
Failure to follow the advice of a physician, registered nurse, physician’s assistant, or public health official who has recommended vaccines may endanger my child’s/my health or life and others who come into contact with my child/me.
I may change my mind at any time and accept vaccination(s) for my child/myself in the future.
3 Under Colorado law, you have the option to exclude your child’s/your information from CIIS. To opt out of CIIS, go to: www.colorado.gov/cdphe/ciis-opt-outprocedures. Please be advised that you will be responsible for maintaining your child’s/your immunization records to ensure school compliance.
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