Student Exemption From Mandatory Immunization In New Jersey (Page 3 of 3) in pdf

Student Exemption From Mandatory Immunization In New Jersey Page 3

Following is a Sample Medical Excuse Letter that any reasonable physician should be able to

sign, based upon the parents' assertion of a history of allergic reaction.

Immunization Medical Excuse Letter

Date: ______________________________________________

Name of Student: ____________________________________

Name of Physician: _________________________________

Address of Physician: ________________________________

Name of School: ____________________________________

Dear School Nurse:

This letter is provided as a Medical Excuse for the above named student to be excused

from receiving the Hepatitis B or other Vaccination.

The medical history of the student, as relayed by the parents, indicates an allergic

reaction to a previous vaccination or vaccine component.

Such reaction is listed as a “true contraindication” in the Advisory Committee on

Immunization Practices (ACIP) Guidelines, found at:

On Table 5, Guide to

Contraindications, it is stated, in regard to the Hepatitis B vaccine, "allergic reaction after a

previous dose or to a vaccine component" is a "true contraindication" justifying the

withholding of further vaccination.

___________________________

Signature of MD

Student Exemption From Mandatory Immunization In New Jersey Page 3