Texas Department of State Health Services
Immunizations
Stock No. E11-13159
Rev. 09/2021
Frequently Asked Questions
Vaccine Exemption for
Reasons of Conscience
Q. How do I obtain a vaccine exemption for reasons of conscience?
A. YoumustrequestavaccineexemptionafdavitformbysubmittingarequestthroughtheU.S.PostalService,
commercialcarrier,fax,oronline.Phoneandemailrequestsarenotaccepted.PersonalpickupatDSHS
isnotpermitted.ALLafdavitformswillbemailedtoyouviatheU.S.PostalService.Therequestmust
includethenameanddateof birthof eachstudentforwhomaformisbeingarequestedandacomplete
returnmailingaddress.
Hand Deliver:
Departmentof StateHealthServices(DSHS)
Lobby
1100West49thStreet
Austin,TX78756
Mailing Address:
Departmentof StateHealthServices(DSHS)
Immunizations
MC-1946
P.O.Box149347
Austin,TX78714-9347
Fax: (512) 776-7544
Secure online request form for exemption affidavit:
https://co-request.dshs.texas.gov/
Q. What is the turnaround time for conscientious exemption requests?
A. Uponreceipt,allexemptionrequestswillbeprocessedandmailedwithinapproximately2weeks.Thistime
periodallowssufcienttimeformaildelivery.
Q. What information will be listed on the vaccine exemption afdavit form I receive?
A. Informationontheformwillincludethestudent’snameanddateof birth;alistof requiredvaccinesfor
whichexemptionsmayberequested;astatementfortheparent,guardian,orstudent,if overtheageof 18,
statingthattheinformationprovidedontheformistrueandcorrectandacknowledgementthattheyhave
readtheattachedinformationentitledTheBenetsandRisksof Vaccinations.Thevaccineexemption
afdavitformmustbesignedinfrontofanotarypublic.
Q. How many vaccine exemption afdavit forms can I request at a time?
A. Youcanrequestuptovevaccineexemptionafdavitformsperstudentatatime.
Q. What should I do with the vaccine exemption afdavit form?
A. Aftertheoriginalvaccineexemptionafdavitformissignedandnotarized,youmustsubmitittothe
student’sschool,child-carefacility,college,oruniversity.
Q. How long will my vaccine exemption afdavit remain valid?
A. Eachindividualvaccineexemptionafdavitisvalidfortwoyearsfromthedateitisnotarized.
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Texas Department of State Health Services
Immunizations
Stock No. E11-13159
Rev. 09/2021
Q. What happens if I lose the original vaccine exemption afdavit?
A. Photocopiesof thevaccineexemptionafdavitformarenotvalid.If youlosetheexemptionafdavit,you
mustsubmitanewrequestfollowingthesameproceduresusedtoobtaintherstform.
Q. What if my student changes schools?
A. Thevaccineexemptionafdavitispartof thestudent’sschoolrecordsandshouldbesenttothenewschool
withotherschoolrecords.
Q. What will happen to the information collected on my student?
A. AllinformationincludedintherequestfortheafdavitthatwassubmittedtoDSHSwillbereturnedto
youalongwiththevaccineexemptionafdavitforms.DSHSwillsolelybeabletoreportonthenumberof
afdavitrequestsandzipcode.Nootherinformationwillbemaintained.
Q. Does my student have a 30-day provisional enrollment in school while awaiting the vaccine
exemption form?
A. No.Admissiontoaschoolisnotalloweduntilrecordsareproducedshowingthat(1)thestudenthasbeen
immunizedinaccordancewiththerules;(2)thestudenthasanexemptionafdavitfromimmunization
requirementsonlewiththeschoolinaccordancewiththerules;or(3)thestudentisentitledtoprovisional
enrollment.
Q. What is required for school enrollment if I want my student to be exempted from some vaccines but
not all of them?
A. Youwillneedtwodifferentimmunizationdocuments:1)anofcialnotarizedDSHSvaccineexemption
afdavitforthosevaccinesthatyouhavechosenforreasonsofconsciencetohaveyourchildexemptfrom;
and2)avalidimmunizationrecordindicatingthemonth,date,andyeareachvaccineforwhichyourchildis
notexemptwasadministered,withappropriatevalidationbyaphysicianorpublichealthclinic.
Q. If I currently have a religious exemption for vaccinations on le with the school do I need to obtain
a new vaccine exemption form?
A. No.If youhadareligiousexemptionformledattheschoolpriortoSeptember1,2003youdonotneed
anewvaccineexemptionafdavitform.Thereligiousexemptiononleremainsvalid.Ifyouareclaiming
exemptionsafterSeptember1,2003,youwillneedtohaveanexemptionafdavitforreasonsofconscience
onlewiththeschool.
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Frequently Asked Questions
Vaccine Exemption for
Reasons of Conscience
Texas Department of State Health Services
Immunizations
Stock No. E11-13159
Rev. 09/2021
Page3of 3
Q. What should I expect if there is a vaccine-preventable disease outbreak - such as measles - at a
school?
A. Whenyousignavaccineexemptionafdavitform,youalsoacknowledgethatyouunderstandthatyour
exemptedstudentmaybeexcludedfromschoolattendanceintimesof emergencyorepidemicdeclaredby
theTexasCommissionerof Health.
Q. Does this new vaccine exemption option mean that vaccinated students may be attending school
with other students who are not fully vaccinated?
A. Yes.
Q. Can an expectant parent request a vaccination exemption afdavit form for an unborn child?
A. No.Becausethechild’snameanddateof birtharerequiredwhenthevaccineexemptionafdavitformis
requested,expectantparentsmustwaituntilafterthechildisborntorequestthevaccineexemptionafdavit
form.
Q. Are there other reasons a child/student may be exempted from vaccination requirements?
A. Yes.Achildmaybeexemptedfromoneormorevaccinationsformedicalreasons,historyof disease,or
serologic(blood)evidenceof immunity.
MedicalReasons
Theparent,guardian,orstudentmustprovidetheschoolwithacerticatesignedbyaphysician(Doctorof
Medicine,M.D.orDoctorof Osteopathy,D.O.),registeredandlicensedtopracticemedicineintheUnited
States,whichstatesthat,inthephysician’sopinion,theimmunizationrequiredwouldbeinjurioustothe
student’shealthandwell-beingortoanyof thestudent’sfamilyorhouseholdmembers.Unlessalifelong
conditionisspecied,thiscerticateisvalidforoneyearfromthedatesignedbythephysicianandmustbe
renewedeveryyearfortheexclusiontoremainineffect.
SerologicEvidenceof ImmunitytoDisease
Serologicconrmationsof immunitytomeasles,rubella,mumps,hepatitisA,hepatitisB,orvaricellaare
acceptable.Evidenceof measles,rubella,mumps,hepatitisA,hepatitisB,orvaricellaillnessesmustconsist
of avalidlaboratoryreportthatindicatesconrmationof eitherimmunityorinfection.
Historyof Disease
Awrittenstatementfromaparent(orlegalguardian,managingconservator),schoolnurse,studentover
theageof 18,orphysicianattestingtothestudent’spositivehistoryof varicelladisease(chickenpox),orof
varicellaimmunity,isacceptableinlieuof avaccinerecordforthatdisease.(Seeformat
http://www.dshs.state.tx.us/immunize/docs/c-9.pdf)
Frequently Asked Questions
Vaccine Exemption for
Reasons of Conscience