Immunization Non-Medical Exemption Form - Religious And Personal Belief (Page 2 of 2) in pdf

Vaccine Preventable Disease Information

The information provided below is to ensure parents/guardians/students are informed about the risks of not vaccinating.

Diphtheria, tetanus, pertussis (DTaP, Tdap) - Unvaccinated children may be at increased risk of developing diphtheria, tetanus

and/or pertussis if exposed to these diseases. Serious symptoms and effects of diphtheria include heart failure, paralysis,

breathing problems, coma, and death. Serious symptoms and effects of tetanus include “locking” of the jaw, difficulty

swallowing and breathing, seizures, painful tightening of muscles in the head and neck, and death. Serious symptoms and effects

of pertussis (whooping cough) include severe coughing fits that can cause vomiting and exhaustion, pneumonia, seizures, brain

damage, and death. For more information:

and

Haemophilus influenza type b (Hib) – Unvaccinated children may be at increased risk of developing invasive Hib disease if

exposed to this disease. Serious symptoms and effects include bacterial meningitis, pneumonia, severe swelling in the throat,

permanent neurologic damage including blindness, deafness, and mental retardation, infections of the blood, joints, bones, and

covering of the heart, and death. For more information:

Hepatitis B - Unvaccinated children may be at increased risk of developing hepatitis B if exposed to this disease. Serious

symptoms and effects include jaundice, life-long liver problems such as liver damage, scarring, liver cancer, and death. For

more information:

Inactivated poliovirus (IPV) – Unvaccinated children may be at increased risk of developing polio if exposed to this disease.

Serious symptoms and effects include paralysis of muscles that control breathing, meningitis, permanent disability, and death.

For more information:

Measles, mumps, rubella (MMR) - Unvaccinated children may be at increased risk of developing measles, mumps, and/or rubella

if exposed to these diseases. Serious symptoms and effects of measles include pneumonia, seizures, brain damage, and death.

Serious symptoms and effects of mumps include meningitis, painful swelling of the testicles or ovaries, sterility, deafness, and

death. Serious symptoms and effects of rubella include rash, arthritis, and muscle or joint pain. If a pregnant woman gets

rubella, she could have a miscarriage or her baby could be born with serious birth defects such as deafness, heart problems, and

mental retardation. For more information:

Pneumococcal conjugate (PCV13) or polysaccharide (PPSV23) - Unvaccinated children may be at increased risk of developing

pneumococcal disease if exposed to this disease. Serious symptoms and effects include pneumonia, lung infections, blood

infections, meningitis and death. For more information:

and

Varicella (chickenpox) – Unvaccinated children may be at increased risk of developing varicella if exposed to this disease.

Serious symptoms and effects include severe skin infections, pneumonia, brain damage, and death. For more information:

Required Vaccines for School Entry -

Place an “X” next to each vaccine you are declining.

Diphtheria, tetanus, pertussis (DTaP)

Inactivated poliovirus (IPV)

Tetanus, diptheria, pertussis (Tdap)

Measles, mumps, rubella (MMR)

Haemophilus influenza type b (Hib)

Pneumococcal conjugate (PCV13) or polysaccharide (PPSV23)

Hepatitis B

Varicella (chickenpox)

I am the parent/guardian of the above-named student or am the student himself/herself (emancipated or over 18 years of age) and

am declining the vaccine(s) indicated above due to a religious or personal belief that is opposed to vaccines. The information I have

provided on this form is complete and accurate.

•

I may change my mind at any time and accept vaccination(s) for my child/myself in the future.

•

I can review evidence-based vaccine information at , or

for additional information on the benefits and risks of vaccines and the diseases they prevent.

•

I can contact the Colorado Immunization Information System (CIIS) at

or my health care provider to

locate my child’s/my immunization record.

I acknowledge that I have read this document in its entirety.

Parent/Guardian/Student (emancipated or over 18 yrs old) signature: __________________________________ Date: ____________

I authorize my/my student’s school to share my/my student’s immunization records with state/local public health agencies and

the Colorado Immunization Information System, the state’s secure, confidential immunization registry.

Parent/Guardian/Student (emancipated or over 18 yrs old) signature: _________________________________ Date: ___________

Under Colorado law, you have the option to exclude your child’s/your information from CIIS at any time. To opt out of CIIS, go to:

out-procedures. Please be advised you will be responsible for maintaining your child’s/your immunization records to ensure school compliance.

Immunization Non-Medical Exemption Form. August 2016

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Immunization Non-Medical Exemption Form - Religious And Personal Belief Page 2

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