Face Mask Requirement for School Attendance
Medical Exemption Statement for Children 2-18 Years of Age
Instructions:
1.
2.
3.
4.
Complete information (name, DOB etc.).
Complete contraindication/precaution information.
Complete date exemption ends, if applicable.
Complete medical provider information. Retain copy for file. Return original to facility or person requesting form.
1. Patient’s Name
2. Patient’s Date of Birth
3. Patient’s Address
4. Name of Educational Institution
Please describe the patient’s contraindication(s)/precaution(s) here:
Date exemption ends (if applicable):
Name (print)
NYS Medical License #
Address
Telephone
Date:
Signature
For Institution Use ONLY: Medical Exemption Status
Accepted Not Accepted Date:
Currently acceptable diagnoses to justify exemption:
A New York State licensed physician (MD, DO, or Nurse Practitioner (NP), or Physician Assistant (PA), or licensed clinical Psychologist
(PhD/PsyD)) must complete this medical exemption statement and provide their information below:
• A previously documented neuromuscular disorder that makes it difficult for a child to remove a mask themselves, or
• A child with a previously diagnosed, severe developmental/behavioral problem, or
• A child with a diagnosis of Serious Emotional Disturbance (SED) or other significant mental health problem, currently in the care
of a behavioral health team, and it is believed by this team that wearing a face mask would lead to worsening emotional harm.
