Medical Exemption Statement Template Page 2
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1
2Vaccine
X
PCV
Contraindications
□
Severe allergic reaction (e.g., anaphylaxis) after a previous dose (of PCV7, PCV13, or any diphtheria toxoid--containing
(not currently required
by ARM)
vaccine) or to a component of a vaccine (PCV7, PCV13, or any diphtheria toxoid-containing vaccine)
Precautions
□
Moderate or severe acute illness with or without fever
Hib
Contraindications
□
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
□
Age <6 weeks
Precautions
□
Moderate or severe acute illness with or without fever
MMR
Contraindications
□
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
□
Known severe immunodeficiency (e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency,
long-term immunosuppressive therapy, or patients with HIV infection who are severely immunocompromised )
□
Pregnancy
Precautions
□
Recent (<11 months) receipt of antibody-containing blood product (specific interval depends on the product)
□
History of thrombocytopenia or thrombocytopenic purpura
□
Need for tuberculin skin testing
□
Moderate or severe acute illness with or without fever
Tdap
Contraindications
□
(not currently required
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
□
by ARM)
Encephalopathy within 7 days after receiving a previous dose of DTP, DTaP, or Tdap
Precautions
□
Guillain-Barre′ syndrome ≤6 weeks after a previous dose of tetanus toxoid-containing vaccine
□
Progressive neurological disorder, including progressive encephalopathy, or uncontrolled epilepsy, until the
condition has stabilized
□
Arthus reaction following a previous dose of any vaccine containing tetanus toxoid or diphtheria
□
Moderate or severe acute illness with or without fever
Contraindications
Varicella
□
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
□
Known severe immunodeficiency (e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency,
long-term immunosuppressive therapy, or patients with HIV infection who are severely immunocompromised )
□
Pregnancy
Precautions
□
Recent (<11 months) receipt of antibody-containing blood products (interval depends on product)
Moderate or severe acute illness with or without fever
□
For medical conditions not listed, please note the vaccine(s) that is contraindicated and a description of the condition
__________________________________________________________________________________________
__________________________________________________________________________________________
Attach most current immunization record
Instructions
Purpose: To provide Montana physicians with a mechanism to document
Date exemption ends_______________________________
true medical exemptions to vaccinations
____________________________________________
Preparation: 1. Complete patient information (name, DOB, address, and
Completing physician’s name (please print)
school/childcare facility)
2. Check applicable vaccine(s) and exemption(s)
3. Complete date exemption ends and physician information
Address__________________________________________
4. Attach a copy of the most current immunization record
5. Retain a copy for file
6. Return original to person requesting form
Phone____________________________________________
Reorder:
Immunization Program
1400 Broadway, Room C-211
_________________________________________________
Helena, MT 59620
Completing physician’s signature
(406) 444-5580
(only licensed physicians may sign)
Montana Code Annotated
Questions?
Call (406) 444-5580
20-5-101-410: Montana Immunization Law
52-2-735: Daycare certification
Administrative Rules of Montana
37.114.701-721: Immunization of K-12, Preschool, and Post-secondary schools
37.95.140: Daycare Center Immunizations, Group Daycare Homes, Family Day Care Homes
Form No. IZ HES101A (Rev 8/2012)
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