Fill - Free fillable Request for Medical Exemption from Mandatory COVID-19 Immunization PDF form

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

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.

Healthcare Provider Name (please print):

Specialty:

NPI #:

License #:

State of Licensure:

Phone:

Fax:

Email Address:

Address:

City:

State:

Zip Code:

Signature:

Date:

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.

Fill Online, Printable, Fillable, Blank Request for Medical Exemption from Mandatory COVID-19 Immunization Form

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Fillable Request for Medical Exemption from Mandatory COVID-19 Immunization

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