Looking for a Nc Dhhs Forms And Templates? Download it for free!

Vaccine

EIPV

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Precautions

Pregnancy

Moderate or severe acute illness with or without fever

Hepatitis B

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Precautions

Infant weighing <2,000 grams if mother is documented hepatitis B surface antigen (HbsAg)-negative at

the time of the infant’s birth

Moderate or severe acute illness with or without fever

Hib

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Age <6 weeks

Precaution

Moderate or severe acute illness with or without fever

MMR

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Pregnancy

Known severe immunodeficiency (e.g., hematologic and solid tumors or severely symptomatic human

immunodeficiency virus [HIV] infection)

Precautions

Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on product)

History of thrombocytopenia or thrombocytopenic purpura

Moderate or severe acute illness with or without fever

Tdap

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Severe allergy to latex

Encephalopathy within seven days after receipt of a previous dose of DTP or DTaP

Precautions

Guillian-Barré syndrome ≤6 weeks after a previous dose of tetanus toxoid-containing vaccine

Progressive neurologic 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

Pregnancy

Varicella

Contraindications

Severe allergic reaction after a previous dose or to a vaccine component

Substantial suppression of cellular immunity

Pregnancy

Precautions

Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on product)

Moderate or severe acute illness with or without fever

Attach most current immunization record.

Instructions

Purpose:

To provide physicians with a mechanism to document true

Date exemption ends _____________________________

medical exemptions.

Preparation:

1. Complete patient information (name, DOB, address

________________________________________________

and school/child care).

N.C. Physician’s Name (please print)

2. Check applicable vaccine(s) and exemption(s).

3. Complete date exemption ends and physician

Address ________________________________________

information.

4. Attach a copy of the most current immunization

________________________________________________

record.

5. Retain copy for file.

Phone __________________________________________

6. Return original to person requesting form .

Reorder:

Immunization Branch

________________________________________________

1917 Mail Service Center

N.C. Physician’s Signature/Date

Raleigh, NC 27699-1917

Phone: 1-877-873-6247

For questions call (919) 707-5550

DHHS 3987 (Revised 3/08)

Immunization (Review 3/10)

Medical Exemption Statement - North Carolina Department Of Health And Human Services Page 2

Related Articles

Related forms

Related Categories