Fillable COVID-19 Vaccination MEDICAL/RELIGIOUS OBSERVATION DECLINATION FORM (Wayne State University)

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COVID-19 Vaccination MEDICAL/RELIGIOUS OBSERVATION DECLINATION FORM (Wayne State University)

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The COVID-19 Vaccination MEDICAL/RELIGIOUS OBSERVATION DECLINATION FORM (Wayne State University) form is 3 pages long and contains:

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  • 14 check-boxes
  • 20 other fields

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File type: PDF

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COVID-19 Vaccination – MEDICAL/RELIGIOUS
OBSERVATION DECLINATION FORM
Name:
Date:
AccessID:
Date of Birth:
Contact Phone Number:
Please select all that apply: WSU student WSU employee
Individuals who have a medical condition that would prevent them from being able to receive vaccines
must present documentation from their physician/practitioner.
Have you ever had a life-threatening allergic reaction after a dose of COVID-19 vaccine? Yes
No
If Yes, please provide the manufacturer of the vaccine, approximate date of COVID-19 vaccine administration and
a brief description of your allergic reaction:
No
Have you ever had a life-threatening allergic reaction to any of the vaccine ingredients? Yes
If Yes, name (s) of the ingredients:
Signature:
HEALTH CARE PROVIDER TO COMPLETE
A Michigan-licensed physician/practitioner to complete and sign request for exemption.
Physician/Practitioner Statement: The above-named individual from WSU is under my care. I have reviewed the Covid-19
vaccine recommendations from the Centers for Disease Control (CDC) and request the following medical exemption based
on a true medical contraindication as outlined by the CDC:
Permanent Exemption related to:
Severe allergic reaction (e.g., anaphylaxis) after a previous dose of Covid-19 vaccine
History of anaphylactic reaction to Covid-19 vaccine ingredient:
Temporary Exemption related to: Pregnancy
Other
This individual will be able to receive vaccine on or after (date):
Please Indicate Vaccine manufacturer(s) you are exempting student from:
Provider Name (print): MI Medical License #:
Address: Phone:
Signature: Date:
As options for the Covid vaccine expand, there may be vaccines available that will be medically safe for the
individual. The Campus Health Committee reserves the right to request recertification of this exemption.
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RELIGIOUS/SPIRITUAL EXEMPTION REQUEST
The University will grant exemption to the vaccine requirement when an individual’s sincerely-held religious beliefs preclude
vaccination. A religious exemption will not be granted based on a philosophical, moral, or conscientious objection. Please
describe below why your sincerely-held religious beliefs preclude you from receiving the COVID-19 vaccination.
Please identify your sincerely held religious belief, practice or observance that is the basis for your request for an exemption
from the Covid-19 vaccine requirement:
Please briefly explain how your sincerely held religious belief, practice or observance conflicts with the University's Covid-19
vaccine requirement:
Please indicate whether you are opposed to all vaccines, and if not, the religious basis on which you object to the Covid-19
vaccine.
Please provide any additional information that you think might be helpful in reviewing your religious exemption request:
The Campus Health Committee reserves the right to request additional information reasonably needed to evaluate your request.
Applicant Signature:
Campus Health Committee Determination of Exemption Request:
Accepted
Not Accepted
Signature:
Everyone must upload this form to the hyperlink provided.
The Campus Health Committee will determine valid exceptions.
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IMPORTANT NOTE: This exemption is only valid for the 2021-2022 academic year. The University may
require additional request for exemption based on the needs of the indivudals’s respective school and
academic program. As an individual with this exemption, I understand and certify:
• I will comply with testing as directed by the University; at minimum, this will include mandatory testing
prior to the start of each semester and weekly prevalence testing throughout the academic year.
• I will submit to self-isolation or quarantine in a designated University facility (if I live on-Campus) or in my
own residence or an alternate location of my choice (if I live off-Campus) and follow the directions of the
Campus Health Center regarding monitoring and self-care in any circumstance (1) where there is a
reasonable belief that I have been exposed to an individual who has tested positive or suspected positive
for COVID-19,
(2) when I may be experiencing any symptom(s) consistent with COVID-19, or (3) if I test positive or suspected
positive for COVID-19, until such time as my symptoms resolve and I may be medically cleared to resume
participation in University activities.
• I will respond promptly to outreach from the Campus Health Center and provide all requested information
to them regarding my contacts with individuals and cooperate with any contact tracing or other information
gathering processes designed to identify risks of virus transmission to others.
• I will follow any additional public health protective measures, which may evolve based on the overall course
of the pandemic, as required by University policy. I understand I may be subject to additional requirements if
my academic program requires me to be in a clinical settings.
• In the event of an outbreak or a threatened outbreak of COVID-19, I will comply with any University
directive that may bar me from living, learning, and/or participating in University-approved activities on-
Campus temporarily or permanently. I understand that any such restrictions will not entitle me to reductions
in tuition, housing charges, or other University fees.
I certify that the information I have provided in connection with this request is accurate and complete and
the exemption may be revoked if any false information has been used to request an exemption. I understand
that although the University holds the health and safety of its community as paramount, there is no
guarantee that I will not be exposed to or infected with COVID-19.
I have reviewed the CDC’s information on the benefits of getting a COVID-19 vaccine (https://www.cdc.gov/
coronavirus/2019-ncov/vaccines/vaccine-benefits.html) and understand that, as an unvaccinated individual,
my physical presence as well as participation and utilization of facilities, services, and programs at the
University may carry heightened risks that cannot be eliminated regardless of the care and reasonable
efforts taken to avoid and mitigate those risks. I also understand that I may be at higher risk for severe
complications from COVID-19 if I have particular conditions identified by the CDC. Despite these risks, I chose
not to be vaccinated. I have read and fully understand my obligations as described above and request this
exemption related to COVID-19 vaccine.
Applicant Signature:
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COVID-19 Vaccination MEDICALRELIGIOUS OBSERVATION DECLINATION FORM (Wayne State University)

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Completed 7 October 2021

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