Medical Exemption Statement Template printable pdf download

Montana Department of Public Health and Human Services (DPHHS)

Communicable Disease Control and Prevention Bureau • Immunization Program

Medical Exemption Statement

Physician: Please mark the contraindications/precautions that apply to this patient, then sign and date the back of the form. The signed

Medical Exemption Statement verifying true contraindications/precautions is submitted to and accepted by schools, childcare

facilities, and other agencies that require proof of immunization. For medical exemptions for conditions not listed below, please note

the vaccine(s) that is contraindicated and a description of the medical condition in the space provided at the end of the form. The State

Medical Officer may request to review medical exemptions.

Attach a copy of the most current immunization record

Name of patient_______________________________________________________________DOB__________________

Name of parent/guardian______________________________________________________________________________

Address (patient/parent)______________________________________________________________________________

School/child care facility______________________________________________________________________________

For official use only:

Check if reviewed by public health

Name/credentials of reviewer:_______________ ______ Date of review:__________

Medical contraindications for immunizations are determined by the most recent General Recommendations of the Advisory Committee on

Immunization Practices (ACIP), U.S. Department of Health and Human Services, published in the Centers for Disease Control and Prevention’s

publication, the Morbidity and Mortality Weekly Report.

A contraindication is a condition in a recipient that increases the risk for a serious adverse reaction. A vaccine will not be administered when a

contraindication exists.

A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine

to produce immunity. Under normal conditions, vaccinations should be deferred when a precaution is present

Contraindications and Precautions

Vaccine

Hepatitis B

Contraindications

□

 Serious allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or vaccine component

(not currently required

by Administrative Rule

Precautions

of Montana [ARM])

□

 Moderate or severe acute illness with or without fever

DTaP

Contraindications

 Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

□

 Encephalopathy within 7 days after receiving previous dose of DTP or DTaP

□

Precautions

 Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, progressive

□

encephalopathy; defer DTaP until neurological status has clarified and stabilized

 Fever ≥40.5°C (105°F) within 48 hours after vaccination with previous dose of DTP or DTaP

□

 Guillain-Barre′ syndrome ≤6 weeks after a previous dose of tetanus toxoid-containing vaccine

□

 Seizure ≤3 days after vaccination with previous dose of DTP or DTaP

 Persistent, inconsolable crying lasting ≥3 hours within 48 hours after vaccination with previous dose of DTP/ DTaP

□

 History of arthus-type hypersensitivity reactions after a previous dose of tetanus toxoid-containing vaccine

 Moderate or severe acute illness with or without fever

□

Contraindications

DT, Td

□

 Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Precautions

□

 Guillain-Barre′ syndrome ≤6 weeks after a previous dose of tetanus toxoid-containing vaccine

□

 History of arthus-type hypersensitivity reactions after a previous dose of tetanus toxoid-containing vaccine

□

 Moderate or severe acute illness with or without fever

Contraindications

IPV

□



Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Precautions

□

 Pregnancy

□

 Moderate or severe acute illness with or without fever

Form No. IZ HES101A (Rev 8/2012)

Medical Exemption Statement Template

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