Medical Request For Immunization Exemption - Nyc Department Of Education
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1MEDICAL REQUEST FOR IMMUNIZATION EXEMPTION
FOR DOE USE ONLY
Student’s name
DOB
_______________________________________________________________________
____/____/____
ATS DBN
OSIS #
FOR THE USE OF REQUESTING MEDICAL PROFESSIONAL
INSTRUCTIONS:
This form is to be completed by the student’s treating physician who must be licensed in NYS. The medical basis for exemption must be
based on guidance from the Centers for Disease Control and Prevention (CDC), Advisory Committee on Immunization Practices (ACIP), and the American
Academy of Pediatrics (AAP) Red Book.
Failure to provide contact information and/or sufficient documentation will delay the review process. Requests for additional information, made
either by telephone or in writing must be received by the Office of School Health within 2 weeks or the request for medical exemption will be denied.
I request a medical exemption for (student’s name) __________________________________________ for the following required immunization(s)
and certify that the particular immunization will be detrimental to the child’s health:
Hepatitis B
DTaP/Tdap
Polio
MMR
Varicella MenACWY
For children up to the 5th birthday: PCV13
Hib
NOTE:
•
Exemption from MMR based on egg allergy will not be accepted. Guidelines are explicit that egg allergy, even if anaphylactic, is not a valid contraindication.
•
Autism and/or developmental delay in the child or family member is not a valid reason for exemption for any vaccine and will not be accepted.
•
Contact with immunosuppressed persons by a healthy individual is not a valid contraindication for exemption and will not be accepted.
•
Pregnancy in the household or contact with a pregnant woman is not a valid contraindication for exemption and will not be accepted.
Medical exemptions are no more than one year and must be renewed at the start of each school year.
•
__________________________________________________________________________________________________
Explanation:
___________________________________________________________________________________________________________
I am the student’s physician PRINT CLEARLY
NAME
Physician’s original signature _______________________________________________ Degree: ________
License #
_____ Physician
Stamp
_____ Fellow
_____ Resident
Contact information
Direct telephone line ___/___/___ ___/___/___ ___/___/___/__ ext __/__/__/__
Cell ___/___/___ ___/___/___ ___/___/___/___
Date ________________
PARENT/GUARDIAN CONSENT FOR RELEASE OF INFORMATION
I authorize __________________________ (health professional) to provide physicians and nurses of the New York City Department of Health and Mental Hygiene
and the New York City Department of Education and their medical consultants with information contained in my child’s medical record, including, but not limited to,
copies of laboratory and or other examinations supporting this request for medical exemption for required immunizations.
Parent/Guardian’s signature ____________________________________________________________
Parent/Guardian’s name (PRINT) _________________________________________________________
Date ______________________
FOR OFFICE OF SCHOOL HEALTH USE ONLY
Exemption ____ APPROVED _____ DENIED
Length of exemption:____________________
Physician comments:
___________________________________________________________________________________________________________________________________
Reviewed by: ___________________________________________________________________
Date: ________________________________
Revised 09/26/17
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