BACKGROUND The state of North Carolina has statutes that require age-appropriate immunization as recommended by the U.S. Public Health Service. Provisions of this statute allow for criminal misdemeanor charges and injunctions to be brought against parents who do not have their children immunized on time. The decision to invoke the age-appropriate immunization statute rests with the health director of each county. This study was performed to determine if the county health directors were aware of this statute and whether they had ever utilized it to enforce age-appropriate immunization. METHODS All health department directors in the state of North Carolina (N = 86) received letters inviting them to complete a 20-minute structured phone interview at a time of their convenience. Specific questions addressed their knowledge of the statutes and the specific penalties available. Additional questions addressed their attitudes and beliefs about the law and what they believed the state government could do to assist in enforcing the law. RESULTS Interviews were completed for 75 of the 86 (87%) county health departments or districts. All respondents reported they were aware, prior to receiving the materials informing them of the study, that the state required children to be immunized on time. Over 95% reported they knew the law required age-appropriate immunization and 100% were aware of school/licensed day-care requirements. The vast majority (83%) of county health directors believe that criminal misdemeanor charges and injunctions should be brought against parents for failing to have their child age-appropriately immunized. However, only 5% (n = 4) of health directors reported that their county had ever brought criminal misdemeanor charges, and none had filed an injunction against a parent whose child was not immunized on time. CONCLUSIONS Despite the presence of legal statutes, there have been only rare efforts to compel age-appropriate immunization through enactment and enforcement of criminal penalties on parents. Much of the hesitancy for such efforts likely comes from the fear of the confusing, hard-to-understand legal procedures and from the potential negative impact on public opinion that these tactics may create. Although such actions should be taken only as a last resort, they may be necessary on some occasions.