Connecticut Department Of Public Health Medical Exemption Certification Statement printable pdf download

Connecticut Department of Public Health

Medical Exemption Certification Statement

According to State statutes (Connecticut General Statutes Sections 19a-7f and 10-204a)

no child may be

admitted to a licensed child care program or school without proof of immunization or a statement of

exemption. Parents or guardians claiming a medical exemption on the basis that a given immunization is

medically contraindicated should complete the following statement and attach a letter signed by a

physician licensed to practice medicine stating that in the physician’s opinion, such immunization is

medically contraindicated and return it to the school or child care facility. The letter must include the

child’s name, birth date, the vaccine(s) for which exemption is being filed and the condition that

contraindicates vaccination, as well as the physician’s signature and contact information.

To Whom It May Concern:

As the parent(s)/guardian(s) of __________________________________________,

(Name of student)

I/we are submitting the enclosed documentation from a physician that immunization of this child is

medically contraindicated. Therefore, this child is exempt from receiving the required immunization as

specified by the physician, and shall be permitted to attend a licensed child care program or school except

in the case of a vaccine-preventable disease outbreak.

________________________________/__________

Signature of Parent(s)/Guardian(s)

Date

________________________________/__________

Signature of Parent(s)/Guardian(s)

Date

___________________________________________

Address

___________________________________________

Telephone #

Children with medical exemptions shall be permitted to attend a licensed child care program or school

except in the case of an outbreak of vaccine-preventable disease. In the event of an outbreak of vaccine

preventable disease, all susceptible children will be excluded from child care or school settings based on

public health officials’ determination that the child care facility or school is a significant site for disease

exposure, transmission and spread into the community. Children without proof of immunity, including

children with religious and medical exemptions shall be excluded from these settings for this reason and

will not be able to return until (1) the danger of the outbreak has passed as determined by public health

officials, (2) the child becomes ill with the disease and completely recovers, or (3) the child is immunized.

Med/exempt/cert/form/ rev April 2011

Connecticut Department Of Public Health Medical Exemption Certification Statement