Fillable COVID-19 VACCINATION MEDICAL EXEMPTION REQUEST FORM (Morgan State University)

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COVID-19 VACCINATION MEDICAL EXEMPTION REQUEST FORM (Morgan State University)

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COVID-19 VACCINATION
MEDICAL EXEMPTION REQUEST FORM
If you have an allergy to the COVID-19 vaccine or a specific medical condition that precludes the COVID-19
vaccination requirement and you seek a medical exemption from Morgan State University’s COVID-19
vaccination requirement, please consult with your physician and complete this form and upload this and
supporting documentation to our secured Vaccination portal found on our www.morgan.edu/coronavirus site.
Confidentiality of Information Provided - Requests for exemptions and any documents provided will be kept
confidential.
REQUESTOR
NAME
DATE OF BIRTH
PHONE#
EMAIL
FOR FACULTY AND STAFF ONLY:
DEPARTMENT
TITLE
IMMEDIATE SUPERVISOR
SUPERVISOR’S PHONE#
PHYSICIAN INFORMATION
PHYSICIAN NAME
PHYSICIAN PHONE#
PHYSICIAN ADDRESS
Dear Physician,
Morgan State University requires COVID-19 vaccinations for all students, faculty and staff. A medical
exemption from COVID-19 vaccination is allowed for certain recognized contraindications
(https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html). Please complete the form
below. Thank you.
The individual listed above should not be immunized for COVID-19 for the following reasons (Check all that
apply)
Severe allergic reason (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19
vaccine.
Immediate allergic reaction of any severity to a previous dose or known (diagnosed) allergy to a
component of the vaccine (Vaccine ingredients: https://www.cdc.gov/vaccines/covid-19/info-by-
product/clinical-considerations.html#Appendix-C
a. Which ingredient caused an allergic reaction?_________________________________________
b. What was the reaction? __________________________________________________________
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c. Which brand of the COVID-19 vaccine is contraindicated and why?______________________
d. How long will the medical contraindication last? _______________________________________
Other Medical Reason – Please provide a detailed separate narrative that describes any other medical
reason(s) justifying an exemption.
PHYSICIAN’S AUTHORIZATION
I certify that [individual’s name] ____________________________ has the medical condition checked and
request a medical exemption from COVID-19 vaccination.
Physician’s Signature: ____________________________________ Date: _______________________
(NOTE: Signature Stamp is not accepted)
Physician’s Medical License # _____________________________ NPI No: ______________________
FOR THE REQUESTOR (Students/Faculty/Staff)
Verification and Accuracy:
I verify that the above information I have provided is complete and accurate to the best of my knowledge, and I
understand that any intentional misrepresentation contained in this request may result in disciplinary action which
may include termination/dismissal (faculty/staff) and suspension/expulsion (students). I also understand that my
request for an exemption may not be granted if it is unreasonable or creates an undue hardship for the University.
Printed Name: _______________________________________ Date: _________________
Signature: _______________________________________
MSU ID: _______________________________________
Signature of Parent or Guardian (if under 18 years old)_____________________________________
Printed Name:__________________________ Date:___________________________
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COVID-19 VACCINATION MEDICAL EXEMPTION REQUEST FORM (Morgan State University)

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Completed 8 September 2021

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