Texas Health and Safety Code - HEALTH & SAFETY § 161.0041. Immunization Exemption Affidavit Form

(a) A person claiming an exemption from a required immunization based on reasons of conscience, including a religious belief, under Section 161.004 of this code, Section 38.001, 51.9192, or 51.933, Education Code, or Section 42.043, Human Resources Code, must complete an affidavit on a form provided by the department stating the reason for the exemption.  This subsection does not apply to a person claiming the exemption using the Internet-based process under Section 51.9192(d-3), Education Code.

(b) The affidavit must be signed by the person claiming the exemption or, if the person is a minor, the person's parent, managing conservator, or guardian, and the affidavit must be notarized.

(c) The department shall develop a blank affidavit form for a person to use in claiming an exemption from a required immunization under this section and post the affidavit form in a printable format on the department's Internet website.  A person claiming an exemption from a required immunization may also obtain the affidavit form by submitting a written request for the affidavit form to the department.  A person may not be required to provide any information to obtain a blank affidavit form under this subsection.

(d) The affidavit form shall contain a statement indicating that the person or, if a minor, the person's parent, managing conservator, or guardian understands the benefits and risks of immunizations and the benefits and risks of not being immunized.

(e) The department may maintain a record of the total number of times an affidavit form was accessed on the department's Internet website or requested under Subsection (c).  The department may not maintain a record of any personally identifying information of individuals who download, access, request, or submit an affidavit form under this section.