Vaccination Medical Exemption Form Page 2
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1
2A 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
Signature of Healthcare Provider:
Date:
Medical License Number & State/Country of Issue:
Practice Address:
Provider Phone Number & Email:
Students: Return this completed form to the Student Health Service at the UC campus where you attend.
For Use by University of California Student Health Staff Only:
Campus:
Date Approved:
Address:
Date Denied:
Date of Entry into PnC:
2
9/20/2016
Page 2 of
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