Fillable Request for Medical Exemption: COVID-19 Vaccine (Richland Community College)

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Request for Medical Exemption: COVID-19 Vaccine (Richland Community College)

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Request for Medical Exemption: COVID-19 Vaccine
Pursuant to the Interim Final Rule published by the Centers for Medicare and Medicaid Services
(CMS) on November 5, 2021, and other applicable executive orders, all Richland students and
faculty who attend clinicals must be vaccinated against COVID-19, with exceptions only as
required by Federal law. Richland will consider requests for exemption on an individual basis for
recognized medical contraindications to COVID-19 vaccination and will consider requests for
deferrals due to pregnancy or other temporary medical conditions. All requests for exemption
will be reviewed by Committee. Faculty and students whose exemptions are approved will
instead comply with alternative health and safety protocols as outlined by the clinical sites.
Richland will keep confidential any medical information provided in accordance with applicable
legal standards. Richland may request additional information or documentation as reasonably
needed to determine whether an exemption should be approved. Failure to cooperate in this
interactive process may result in a denial of the request for exemption.
IMPORTANT – In addition to completing the request on page two, a letter from a licensed
practitioner (MD, DO, APN, PA) who is not the individual requesting the exemption and who is
acting within the scope of their practice as defined by applicable state law must be submitted.
The signed and dated letter must include:
1. a statement specifying which of the authorized or licensed COVID-19 vaccines are
clinically contraindicated and the recognized clinical reasons for the contraindications;
AND
2. a statement by the licensed practitioner recommending the faculty or student be
exempted from COVID-19 vaccination requirements based on the recognized clinical
contraindications.
If a temporary delay in vaccination as recommended by the CDC is requested due to clinical
precautions and considerations, including, but not limited to, individuals with acute illness
secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent
plasma for COVID-19 treatment, a signed and dated statement as described above must be
provided by the license practitioner. Information indicating when the temporary condition will
be resolved such that it will be safe to receive COVID-19 vaccination is also required.
Note: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and
other entities covered by GINA Title II from requesting or requiring genetic information of an
individual or family member of the individual, except as specifically allowed by this law. To
comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. “Genetic information” as defined by GINA,
includes an individual's family medical history, the results of an individual's or family member's
genetic tests, the fact that an individual or an individual's family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual's
family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.
R
equest for Medical Exemption: COVID-19 Vaccine
Please read and sign below.
This signed form is a request for medical exemption from COVID-19 vaccination. In addition to
this form, attached is a letter from a licensed practitioner (MD, DO, APN, PA) who is not the
individual requesting the exemption and who is acting within the scope of their practice as
defined by applicable state law. The signed and dated letter includes:
1. a statement specifying which of the authorized or licensed COVID-19 vaccines are
clinically contraindicated and the recognized clinical reasons for the contraindications;
AND
2. a statement by the licensed practitioner recommending the faculty or student be
exempted from COVID-19 vaccination requirements based on the recognized clinical
contraindications.
To reduce the risk of transmission of the COVID-19 virus to me, patients, colleagues and/or the
community, I may be required to complete regular COVID-19 surveillance testing at intervals
determined by the clinical sites to which I am assigned. I may also be required to submit to
other mitigation measures such as additional PPE usage, social distancing, or other reasonable
accommodation, if any are available as determined by the clinical site. My failure to comply
with mitigation measures may be the basis for disciplinary action.
Signing this form constitutes a declaration that the information I am providing is true and
correct, to the best of my knowledge and ability. Any intentional misrepresentation to Richland
may result in disciplinary action.
I have read and fully understand the information on this request for exemption. I also
understand that if my request is approved, it may later be rescinded if there are changes to
pandemic conditions or applicable legal requirements. Exemption from vaccination for any
future years will require the completion and submission of a new request form and may require
the provision of additional information and/or supportive documentation.
________________________________________ ____________________________
Print Name ID Number
________________________________________ _____________________________
Signature Date
Exemption requests should be submitted via email to espanber@richland.edu OR in a sealed
envelope to SHIELD Testing Area W113/W167 during SHIELD Testing Hours. For hard copies,
please write RCC ID# on the envelope.
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Request for Medical Exemption: COVID-19 Vaccine (Richland Community College)

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Completed 22 December 2021

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