Fillable Medical Exemption Form (Kauai Community College)

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Medical Exemption Form (Kauai Community College)

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The Medical Exemption Form (Kauai Community College) form is 2 pages long and contains:

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  • 52 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

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Medical Exemption Form
Instructions for completing Medical Exemption Form:
Section 1: Completed by parent/guardian or student (aged >18 years): Enter child care facility, school, or post-secondary school, and student information
Section 2: Completed by licensed health care provider (MD, DO, ND, APRN-Rx, PA): Check exempted vaccine, contraindication or precaution, or both, and
complete duration of exemption
Section 1: Child Care Facility, School, Post-Secondary School, and Student Information
Student’s Name:
Student’s Date of Birth:
Student’s Home Address
City
State
Zip
Name of Child Care Facility, School, Post-Secondary School
Street Address
City
Zip
I understand that if at any time there is, in the opinion of the Department of Health, danger of an outbreak or epidemic from any communicable disease for which
immunization is required, this exemption from immunization shall not be recognized and the student named above will be excluded from attending the child care
facility, school, or post-secondary school until the Director of Health has determined that the presence of the outbreak no longer exists [HRS §302A-1157].
Parent/Guardian Name [if student <18 years]. (Please print):
__________________________________________________
Parent/Guardian OR Student (if aged >18 years) Signature: ____________________________________________________ Date: _______________
Section 2: For Health Care Provider Use ONLY (MD, DO, ND, APRN-Rx, PA):
VACCINE
CONTRAINDICATIONS* (Check all that apply to this patient):
FROM:
TO:
DTaP
Tdap
DT, Td
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
DTaP/Tdap only: Encephalopathy (e.g., coma,
decreased level of consciousness, prolonged
seizures), not attributable to another identifiable
cause, within 7 days of administration of previous
dose of DTP, DTaP, Tdap
dose of tetanus-toxoid-containing vaccine
History of Arthus-type hypersensitivity reactions
after a previous dose of diphtheria-toxoid-
containing or tetanus-toxoid-containing vaccine
Moderate or severe acute illness with or without
fever
DTaP/Tdap only: Progressive or unstable
neurologic disorder, including infantile spasms,
/ /
/ /
Hib
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
Age <6 weeks
fever
/ /
/ /
Hep A
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
/ /
/ /
Hep B
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
Hypersensitivity to yeast
fever
/ /
/ /
*https://health.hawaii.gov/docd/files/2019/08/HAR11-157_EXHIBIT_B.pdf.
State of Hawaii Department of Health
EPI 8 September 2019
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Section 2: For Health Care Provider Use ONLY (MD, DO, ND, APRN-Rx, PA):
VACCINE
CONTRAINDICATIONS* (Check all that apply to this Patient):
FROM:
TO:
HPV
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
Moderate or severe acute illness with or without
/ /
/ /
MMR
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
Pregnancy
Known severe immunodeficiency (e.g., from
hematologic and solid tumors, receipt of
chemotherapy, congenital immunodeficiency, long-
term immunosuppressive therapy or patients with
HIV infection who are severely immunocompromised)
Family history of altered immunocompetence
containing blood product
History of thrombocytopenia or
thrombocytopenic purpura
Need for tuberculin skin testing or interferon-
gamma release assay (IGRA) testing
Moderate or severe acute illness with or without
fever
/ /
/ /
MCV
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
/ /
/ /
PCV
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose of PCV13 or any diphtheria-toxoid-
containing vaccine or to a component of a vaccine
(PCV13 or any diphtheria-toxoid-containing vaccine)
fever
/ /
/ /
IPV
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
Moderate or severe acute illness with or without
/ /
/ /
Varicella
Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component
Known severe immunodeficiency (e.g., from
hematologic and solid tumors, receipt of
chemotherapy, congenital immunodeficiency, long-
term immunosuppressive therapy or patients with HIV
infection who are severely immunocompromised)
Pregnancy
Family history of altered immunocompetence
blood product
Moderate or severe acute illness with or without
fever
Receipt of specific antiviral drugs (acyclovir,
famciclovir, or valacyclovir) 24 hours before
vaccination
Use of aspirin or aspirin-containing products
/ /
/ /
I certify that in my medical judgement, due to the contraindication(s)/precaution(s) noted above, this student is exempt from the specific vaccine(s) named for
the period indicated.
Health care provider’s name/Title (Please Print): ________________________________________________ License number: ___________________
Address: _________________________________________________________________________________________________________________
Health care provider’s signature: ___________________________________________________________ Date: __________________________
DTaP=Diphtheria, Tetanus, acellular Pertussis, Tdap=Tetanus, diphtheria, acellular pertussis, DT=diphtheria, tetanus, Td=tetanus, diphtheria, Hib=Haemophilus influenzae type B, Hep A=hepatitis A,
Hep B=hepatitis B, HPV=human papillomavirus, MMR=measles, mumps, rubella, MCV=meningococcal conjugate vaccine, PCV=pneumococcal conjugate vaccine, IPV=inactivated poliovirus vaccine
State of Hawaii Department of Health
EPI 8 September 2019
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Medical Exemption Form (Kauai Community College)

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Completed 25 July 2020

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