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CITY UNIVERSITY OF NEW YORK COVID-19 Vaccine Medical (City University of New York)

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CITY UNIVERSITY OF NEW YORK
COVID-19 Vaccine Medical Exemption Request Form
Section I.
To be completed by Student or Parent/Guardian (if student is under 18)
Last Name
First Name
Date of Birth
EMPL ID #
Email
Section II.
To be completed by Medical Provider
Medical Provider certificate of contraindication: I certify that my patient (named above) should not be
vaccinated against COVID-19 because they have one of the following contraindications:
Documented anaphylactic allergic reaction or other severe adverse reaction to any COVID-19 vaccine—
e.g., cardiovascular changes, respiratory distress, or history of treatment with epinephrine or other
emergency medical attention to control symptoms. Generally, does not include gastro-intestinal
symptoms as the sole presentation of allergy. Describe the specific reaction:
Documented allergy to a component of the vaccine—does not include sore arm, local reaction, or
subsequent respiratory tract infection. Describe the specific reaction:
Other documented contraindication. Please Explain: Information to be reviewed by campus Location
Vaccine Authority for approval.
Signature of Healthcare Provider:
Name: (print)
Clinic Stamp/License
Phone Number:
Email:
Once complete, please send this form with supporting documentation to your home campus Location
Vaccine Authority or upload this form with supporting documentation into CUNYFirst for approval. Note:
medical exemptions are not automatically approved.
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CITY UNIVERSITY OF NEW YORK COVID-19 Vaccine Medical (City University of New York)

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Completed 25 February 2022

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