Kansas Certificate Of Immunizations - Form B Medical Exemption printable pdf download

Kansas Certificate Of Immunizations - Form B Medical Exemption

KANSAS CERTIFICATE OF IMMUNIZATIONS - FORM B

MEDICAL EXEMPTION

Student Name:_____________________________________________________

Birthdate:____________

Street Address:________________________________________________________________________________

City:__________________________________________

State:_______

Zip Code:________________

Parent/Guardian:______________________________________________________________________________

Telephone: ____________________________________________

Medical exemption due to _____________________________________________________________________

for the following vaccine(s):

DTaP

MMR

Pertussis Only

Rubella Only

EIPV

Other:_____________________________

I certify the physical condition of this child to be such that the inoculation(s) specified on this form would

seriously endanger the life or health of this child.

Signature:___________________________________________________________

Date:_______________

Name (print):_________________________________________________________________________________

Street Address:________________________________________________________________________________

City:__________________________________________

State:_______

Zip Code:________________

Telephone: ____________________________________________

Medical License Number:___________________________________________

State of Licensure:________

A Medical Doctor (M.D.) Or Doctor of Osteopathy (D.O.) Must complete this affidavit. Annual medical

exemptions shall be documented on this form and attached to the student’s Kansas Certificate of Immunization

(KCI). Annual medical exemptions shall be completed as long as the medical exemption is warranted.

KANSAS IMMUNIZATION PROGRAM

1000 SW Jackson Street, Suite 210

Topeka, Kansas 66612-1274

Phone: 785-296-5591

Fax: 785-296-6210

KCI-Form B

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Kansas Certificate Of Immunizations - Form B Medical Exemption