title: Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures.
abstract: OBJECTIVE
  Our goal was to determine whether school-level variability in implementation of immunization requirements is associated with the likelihood of a child having received an exemption to school immunization requirements.
  
  
  METHODS
  We surveyed 1000 school immunization personnel in Colorado, Massachusetts, Missouri, and Washington. We explored associations between school implementation of immunization requirements and the likelihood of a child having an exemption using logistic regression models.
  
  
  RESULTS
  School policies associated with an increased likelihood of children having exemptions included lack of provision of written instructions for completing the school immunization requirement before enrollment, administrative procedures making it easier to claim an exemption, and granting of philosophical exemptions. In the 2 states we surveyed where philosophical exemptions are not authorized (Massachusetts and Missouri), 17.0% and 18.1% of schools reported permitting philosophical exemptions.
  
  
  CONCLUSIONS
  Inconsistencies in the interpretation and implementation of school immunization laws contribute to variability in rates of exemptions. School policies should be reviewed to ensure consistency with the intent of state laws.
authors.affiliation: Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room W5034, Baltimore, MD 21205, USA. dsalmon@jhsph.edu
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Salmon
authors.forename: Saad B
authors.initials: SB
authors.lastname: Omer
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Moulton
authors.forename: Shannon
authors.initials: S
authors.lastname: Stokley
authors.forename: M Patricia
authors.initials: MP
authors.lastname: Dehart
authors.forename: Susan
authors.initials: S
authors.lastname: Lett
authors.forename: Bryan
authors.initials: B
authors.lastname: Norman
authors.forename: Stephen
authors.initials: S
authors.lastname: Teret
authors.forename: Neal A
authors.initials: NA
authors.lastname: Halsey
mesh_terms: D002648:Child; D003120:Colorado; D003430:Cross-Sectional Studies; D003659:Decision Making, Organizational; D004282:Documentation; D019538:Health Care Surveys; D006801:Humans; D017589:Immunization Programs / Q000458:organization & administration*; D016015:Logistic Models; D008404:Massachusetts; D008923:Missouri; D020380:Needs Assessment; D016017:Odds Ratio; D016134:Organizational Policy; D033282:Parental Consent / Q000331:legislation & jurisprudence / Q000523:psychology / Q000706:statistics & numerical data; D010290:Parents / Q000193:education / Q000523:psychology; D010686:Philosophy, Medical; D017149:Private Sector / Q000706:statistics & numerical data; D017150:Public Sector / Q000706:statistics & numerical data; D012572:School Health Services / Q000458:organization & administration*; D015983:Selection Bias; D011795:Surveys and Questionnaires; D016312:Treatment Refusal / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D014611:Vaccination / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D014861:Washington
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