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.

In the United States, children must be vaccinated in order to attend school, although parents also have the right to request a vaccine exemption. The type of vaccine exemption varies by state but can include exemption for religious, philosophical, medical, and temporary medical reasons. The purpose of this research was to identify the use of provider signature requirements and fees in states during the vaccine exemption process. A questionnaire was sent to immunization managers in the 50 United States, District of Columbia, the United States Indian Health Service, and eight United States territories. The managers were asked if their states required a provider, or other individual, to sign the exemption form prior to granting a vaccine exemption. If a provider signature was required to validate the vaccine exemption form, immunization managers were then asked to identify what type of provider was allowed to sign the form. Immunization managers also reported on whether parents needed to pay a fee in order to obtain a vaccine exemption. A provider signature was most frequently required on medical vaccine exemption forms. For religious exemptions, only two states required a signature from a religious leader. Three states allowed a physician, nurse practitioner, physician assistant, and naturopath to sign philosophical vaccine exemption forms. For medical and temporary medical vaccine exemption forms, the majority of states allowed a physician, nurse practitioner or physician assistant to sign the form. Only one state, Utah, confirmed that a fee was required to obtain religious or philosophical vaccine exemptions. With the hope of reducing vaccine exemption rates, some states employ various obstacles to obtaining and validating a vaccine exemption form, such as requiring a provider signature or charging a fee to process the exemption form. Surprisingly, only a few states required a provider signature on religious and philosophical exemption forms and only one state reported charging a fee to obtain a vaccine exemption form. Identifying these data provides opportunities to further study the effectiveness of various vaccine exemption obstacles.

Background: To prevent the spread of Vaccine Preventable Diseases (VPD’s), school-aged children in the United States are required to receive vaccinations. In certain states, parents have the option to exempt their child from becoming vaccinated due to medical, religious, or personal reasons. The purpose of this research was to identify which states require mandatory vaccination education prior to granting vaccine exemptions and to identify the various types of required vaccination education.Methods: Immunization program managers from states requiring parents seeking exemptions to receive mandatory vaccination education were asked a series of open-ended questions. The interviews were conducted via telephone. The education-related questions identified: 1) which states require mandatory education prior to granting vaccine exemptions; 2) delivery methods for education; 3) standardization of materials; 4) renewal and evaluation of education; 5) the greatest obstacles to providing education; and 6) use of immunization registries to track vaccination education.Results: Ten states reported mandatory vaccination education requirements prior to granting vaccine exemptions. Three methods of vaccination education delivery were identified: printed material, face-to-face education, and/or online technology-driven education. Seven states have standardized vaccination education and use state exemption rates as a means to evaluate the education. Half of states required parents to renew vaccination education, but the time period for renewals varied from state-to-state. There were two general obstacles to delivering vaccination education, namely, lack of resources and lack of parent involvement.Conclusion: Parental education regarding vaccines impacts parents’ decisions to vaccinate their children. The method of delivering mandatory vaccination education varies greatly between states. Each method for vaccination education delivery has inherent advantages and disadvantages, indicating the need for further research to determine which method of education delivery is most effective. A combination of delivery methods may, in fact, be the best option. Identifying the most effective delivery method for vaccination education, as well as the most optimal time period for renewing the education, will assist other states developing mandatory vaccination education materials.