Vaccination Medical Exemption Form

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University of California Medical Exemption Request Form
BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO • SANTA BARBARA • SANTA CRUZ
Full Name of Student:
Campus Student Attends: __________________________________________________
Student’s Medical Record Number:
Student’s Date of Birth:
I, _____________________________________ [Name of licensed MD, DO, PA, NP] have reviewed the University of California
Immunization Exemption Policy, and hereby certify that the above named student has:
A medical condition that contraindicates his/her vaccination with ____________________________ _______________vaccine:
Please check the appropriate box and list below either:
(list only 1 vaccine per section)
a)
The applicable CDC Contraindication to this vaccine*, or
b)
The applicable manufacturer’s vaccine insert contraindication to this vaccine*, or
c)
The physical condition of the person or medical circumstances relating to the person that are such that immunization is
not considered safe, indicating the specific nature of the medical condition or circumstances* that contraindicate
immunization with this vaccine
*REQUIRED: Description of contraindication meeting criteria a, b, or c above:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
This contraindication is:
Permanent or
Temporary
If temporary: In how many months may this vaccine be given? ________________________________
Titers for immunity to this disease: (Please attach photocopies of any titer results if done)
Indicate that he/she is immune
Indicate he/she is NOT immune
Have not yet been obtained
A medical condition that contraindicates his/her vaccination with ____________________________ _______________vaccine:
Please check the appropriate box and list below either:
(list only 1 vaccine per section)
a)
The applicable CDC Contraindication to this vaccine*, or
b)
The applicable manufacturer’s vaccine insert contraindication to this vaccine*, or
c)
The physical condition of the person or medical circumstances relating to the person that are such that immunization is
not considered safe, indicating the specific nature of the medical condition or circumstances* that contraindicate
immunization with this vaccine
*REQUIRED: Description of contraindication meeting criteria a, b, or c above:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
This contraindication is:
Permanent or
Temporary
If temporary: In how many months may this vaccine be given? ________________________________
Titers for immunity to this disease: (Please attach photocopies of any titer results if done)
Indicate that he/she is immune
Indicate he/she is NOT immune
Have not yet been obtained
2
9/20/2016
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