SB 276 California Explained: Medical Exemptions and CAIR-ME

A California medical vaccine exemption lets a child attend school or childcare without one or more required immunizations, but it only counts if a licensed California MD or DO examines the child and issues it through the state’s electronic system, the California Immunization Registry Medical Exemption (CAIR-ME). Since January 1, 2021, a paper note from a doctor is not valid for a new exemption.¹ Personal belief and religious exemptions are not available in California; the medical route is the only route.

What Counts as a Qualifying Medical Reason

An exemption has to rest on a genuine clinical reason a specific vaccine poses a risk to your child. California evaluates exemptions against criteria from the CDC, the Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics (AAP).² Federal guidance divides qualifying conditions into contraindications, which significantly raise the risk of a serious adverse reaction and mean the vaccine should not be given, and precautions, which may increase the risk or reduce effectiveness but at a lower level.³

Most contraindications are temporary and vaccine-specific. A severe allergic reaction to a component of one vaccine, for example, is a contraindication to that vaccine but not necessarily to others, so the exemption has to list each vaccine separately with its own medical justification.⁴

The California Department of Public Health (CDPH) can also accept exemptions based on contraindications or precautions that fall outside strict CDC, ACIP, or AAP criteria, including family medical history, as long as the physician provides written documentation consistent with the relevant standard of care.² The physician still has to show their reasoning in writing.

How to Get an Exemption Through CAIR-ME

The exemption is issued by the physician, not by the parent, but you’ll need to find a physician willing to examine your child and stand behind the certification. The steps look like this:

The physician must hold an active MD or DO license in California and register for a CAIR-ME account by authenticating their license through the Department of Consumer Affairs’ IDEAL system.⁵
The physician has to physically examine the child and certify that the examination was consistent with the relevant standard of care.⁴
The standardized form is completed inside CAIR-ME. Each exempted vaccine is listed separately, with the medical basis for each one.
The physician certifies under penalty of perjury that everything on the form is true, accurate, and complete.⁶
The completed form is transmitted through CAIR, then printed, signed, and submitted to the school or facility your child will attend.⁴

The form also asks the physician to say whether they are your child’s primary care doctor. If they are not, they have to explain why they’re the one issuing the exemption.⁴

How Long the Exemption Lasts

Every exemption is either temporary or permanent, and neither type lasts as long as parents often expect. A temporary exemption can run no more than 12 months from the date it is signed.⁷ After that, you need a new one or your child has to begin the required vaccinations.

Even a permanent exemption expires when your child moves into the next grade span. California recognizes three:

Birth through preschool
Kindergarten (including transitional kindergarten) through 6th grade
7th through 12th grade

At each transition, a new exemption has to be issued through CAIR-ME for the child to stay enrolled without the required immunizations.¹ The one most parents get caught by is the jump from 6th to 7th grade.

How CDPH Reviews Exemptions

CDPH does not review every exemption individually, but its net is wide. A clinically trained staff member (a physician or a registered nurse) reviews all exemptions issued in three situations:

Schools or facilities with an overall immunization rate below 95 percent
Any physician who has submitted five or more medical exemptions in a calendar year, counted from January 1, 2020, onward
Schools or facilities that fail to submit vaccination rate reports to CDPH⁴

During review, the staff member checks whether the exemption meets CDC, ACIP, or AAP criteria and may contact the issuing physician or your child’s primary care doctor for supporting information. If the reviewer thinks the exemption is invalid, the file goes to the State Public Health Officer (or a physician designee from the immunization program) for a second review. Only after that second review can the exemption be revoked.⁴

CDPH notifies the parent or guardian, the issuing physician, the school, and the local public health officer whenever an exemption is denied or revoked.

If Your Child’s Exemption Is Revoked

Revocation does not immediately bar your child from school. Your child can keep attending, but within 30 calendar days of the revocation must begin the immunization schedule required for conditional admittance in order to stay enrolled.⁴ If you neither start vaccinations nor file an appeal within those 30 days, enrollment is at risk.

Filing an appeal within the 30-day window pauses the immunization requirement entirely while the appeal is pending, so your child continues attending without needing to begin vaccinations during that time.⁸ If the revocation is upheld, the immunization schedule kicks in then.

How the Appeal Works

Appeals do not go back to CDPH. They go to the Secretary of the California Health and Human Services Agency (CalHHS), who convenes an independent expert review panel of three licensed physicians with experience in primary care or immunization.⁸ The panel evaluates the appeal against CDC, ACIP, or AAP guidelines, or the relevant standard of care.²

You file the appeal as the parent or guardian, and either you or the issuing physician can submit supporting information. For exemptions filed through CAIR-ME, you have:

30 days from the revocation to file the appeal
30 days to respond to a first request for additional information
15 days to respond to any second request⁸

For older exemptions not filed through CAIR-ME, the response windows are slightly longer: 45 days for the first information request and 20 days for the second.⁸

Both the CDPH review and the CalHHS appeal are exempt from the normal rulemaking and administrative hearing procedures under California’s Administrative Procedure Act, so the process moves faster than a typical administrative proceeding without carrying the same formal hearing protections.²

Exemptions Issued Before 2020

If your child received a medical exemption before January 1, 2020, it was not automatically invalidated. It remains valid until your child moves into the next grade span, at which point a new exemption has to go through CAIR-ME like everyone else’s.¹

Pre-2020 exemptions also get extra protection from revocation. CDPH cannot revoke one unless it was issued by a physician who has been subject to disciplinary action by the Medical Board of California or the Osteopathic Medical Board of California.⁴ If CDPH does revoke one on that basis, you can still appeal through CalHHS, but the appeal skips the independent medical panel because the revocation turns on the physician’s disciplinary record rather than your child’s medical condition.

A Note for Homeless and Foster Families

Families experiencing homelessness sometimes lack vaccination records or immediate access to a physician who can issue an exemption. Under the federal McKinney-Vento Homeless Assistance Act, schools must immediately enroll homeless children and remove barriers to attendance, so a school cannot apply a blanket exclusion for missing immunization records to a McKinney-Vento student. The school has to work with the family to obtain records or vaccinations, and the family retains access to the state medical exemption process.

1
California Legislative Information. California Health and Safety Code 120370
2
California Legislative Information. Today’s Law As Amended – SB-714 Immunizations
3
Centers for Disease Control and Prevention. Contraindications and Precautions
4
California Legislative Information. California Health and Safety Code 120372
5
California Department of Public Health. CAIR-ME How to Register and Log In
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California Legislative Information. Bill Text – SB-276 Immunizations: Medical Exemptions
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California Department of Public Health. Exemption FAQs
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California Health and Human Services Agency. Medical Exemptions Appeal Policy and Procedures