Medical Exemption Form printable pdf download

Medical Exemption Form

Children with medical exemptions shall be permitted to attend school except in the case

of a vaccine-preventable disease outbreak in the school. All susceptible students will be

excluded from school based on public health officials’ determination that the school is a

primary site for disease exposure, transmission and spread into the community.

Students excluded from school for this reason will not be able to return to school until

(1) the danger of the outbreak has passed as determined by public health officials, (2)

the student becomes ill with the disease and completely recovers, or (3) the student is

immunized. For example, for measles the complete incubation period is 18 days from

the onset of symptoms for the last case in the community. Outbreaks like measles may

last for several months.

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

204a), no child may be admitted to school without proof of immunization or a statement

of exemption. Parents or guardians seeking an exemption on the basis that a given

immunization is medically contraindicated should attach to this form a statement signed

by their physician stating that in the physician’s opinion, such immunization is medically

contraindicated and why it is contraindicated (e.g., hypersensitivity to a vaccine

component, demonstrated reaction to vaccine, etc.). In addition, the parents/guardians

should complete the following statement and return it to the school nurse.

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

school except in the case of a vaccine-preventable disease outbreak in the school.

________________________________/__________

Signature of Parent(s)/Guardian(s)

Date

________________________________/__________

Signature of Parent(s)/Guardian(s)

Date

___________________________________________

Address

___________________________________________

Telephone #

Medical Exemption Form