State Of Ohio Legal Immunization Exemption Per Ohio Statute 3313.671 (Exemptions) printable pdf download

State Of Ohio Legal Immunization Exemption Per Ohio Statute 3313.671 (Exemptions)

STATE OF OHIO

LEGAL IMMUNIZATION EXEMPTION

Per OHIO STATUTE 3313.671 (EXEMPTIONS)

Student:_________________________________________________

School:__________________________________________________

City:____________________________________________________

AS LEGAL PARENT(S)/GUARDIAN(S):___________________________________

name(s)

I/WE HEREBY WITHDRAW my/our CONSENT to have my/our child innoculated.

Our beliefs PROHIBIT such practices.

This REQUEST is in accordance with OHIO PURVIEW for

EXEMPTION of GOOD CAUSE, INCLUDING RELIGIOUS CONVICTIONS.

TO BE FILED AS LEGAL PROOF OF

OUR OBJECTION WITH OUR CHILD’S

SCHOOL HEALTH RECORD.

I understand that, in the event of an outbreak of any disease checked above,

the student named above will be subject to exclusion from school for the

duration of the outbreak. Unless provided a statement, signed by a physician,

verifying the student has had the disease in question, the student cannot

attend school until at least two weeks after the last reported case occurs. A

physician diagnosed history or disease is accepted for measles and mumps

only. A positive laboratory test is the only acceptable proof of having had

rubella.

SIGNED:_______________________________________________________________

Signature

Date

_______________________________________________________________________

Signature

Date

This document must be kept on file with the above student’s permanent health record.

State Of Ohio Legal Immunization Exemption Per Ohio Statute 3313.671 (Exemptions)