1
Request for Medical Exemption from Mandatory COVID-19 Immunization
Employee Information
Name of Employee (first, last):
Email Address:
Phone:
Address:
City:
State:
Zip Code:
Healthcare provider to complete this section
Medical contraindications and precautions for immunizations are based on the most recent General Recommendations of
the Advisory Committee on Immunization Practices (ACIP), available at https://www.cdc.gov/vaccines/hcp/acip-
recs/general-recs/contraindications.html or https://redbook.solutions.aap.org/redbook.aspx.
Please check the website to ensure that you are reviewing the most recent ACIP information. Please note that the presence of a
moderate to severe acute illness with or without fever is a precaution to administration of all vaccines. However, as acute illnesses are
short-lived, medical exemptions should not be submitted for this indication.
Vaccine
Exemption Length
ACIP Contraindications and Precautions (check all that apply)
COVID-19
Two mRNA vaccines
(Pfizer-BioNTech,
Moderna) or one viral
vector vaccine
(Janssen [Johnson &
Johnson])
Temporary
through (date):
____________
Permanent
Contraindications:
Severe allergic reaction (e.g., anaphylaxis) after a previous
dose or to 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 human immunodeficiency virus [HIV] infection
who are severely immunocompromised)
Family history of congenital or hereditary immunodeficiency
in first degree relatives (e.g., parents and siblings), unless the
immune competence of the potential vaccine recipient has
been substantiated clinically or verified by a laboratory test
2
Precautions:
Recent (≤ 11 months) receipt of antibody-containing blood
product (specific interval depends on product)
History of thrombocytopenia or thrombocytopenic purpura
Need for tuberculin skin testing or interferon gamma release
assay (IGRA) testing
Attestation by healthcare provider
I am a physician (M.D. or D.O.) or physician assistant (PA) licensed to practice medicine in a jurisdiction of the United
States or an advanced practice nurse licensed in a jurisdiction of the United States.
By signing below, I affirm that I have reviewed the current ACIP Contraindications and Precautions and affirm that the
stated contraindication(s)/precaution(s) is enumerated by the ACIP and consistent with established national standards for
vaccination practices. I understand that I might be required to submit supporting medical documentation. I also understand
that any misrepresentation might result in referral to the New Jersey State Board of Medical Examiners and/or appropriate
licensing/regulatory agency.
NPI #:
License #:
State of Licensure:
Phone:
Fax:
City:
State:
Zip Code:
Signature:
Date:
3
Employee Acknowledgement (to be completed by employee)
Initial next to each of the statements below:
I request exemption from immunization requirements due to my medical condition(s). I understand the
risks of non-immunization. I accept full responsibility for my health, thus removing liability from
Centenary University to the required immunization.
Should I contract COVID-19, I will immediately report it to my supervisor and Human Resources at
Centenary University and comply with the isolation and quarantine procedures specified by the University
and remove myself from the University community if so advised.
I understand and agree to comply with and abide by all University policies and procedures.
I have reviewed the COVID-19 Vaccine & Immunization Record Requirement policy found here.
I certify that the information I have provided in connection with this request is accurate and complete.
Employee Signature
Printed Name of Employee (first, last):
Signature:
Date:
Instructions for Employee Submission
Please note, submitting this request does not guarantee approval. Please allow 7-10 business days for your request to be
processed. Upon review, you will be notified by email if the exemption has been granted. At any time, the University
reserves the right to request additional supporting documentation.
Once the form has been completed by the employee and the healthcare provider, the employee should email the completed
document to Christine Rosado, Human Resources Director at Christine.Rosado@CentenaryUniversity.edu.