Certificate Of Medical Exemption

 

 

Name Of Student ________________________________________________________________    Birthdate_____________________

 

Name Of Parent _______________________________________________________________________________________________

 

Address ______________________________________________________________________________________________________

                                                (Street)                                     (City)                                                (State)                                                 (Zip)

 

Medical Exemption - A medical exemption from vaccination for the above named individual is hereby recommended
on the basis of the following specific condition which is a medically recognized contraindication to the administration
of the required vaccines.

 

 

Vaccines Contraindicated

 

                                                DTaP           DT-Ped.         Td-Adult            IPV           Measles         Mumps                         Rubella           Hep B

Permanently      (    )                (    )             (    )              (    )                  (    )           (    )              (    )             (    )              (    )

Temporarily       (    )             ______        ______         ______           ______      ______         ______       ______            ______

                                             (until date)       (until date)        (until date)           (until date)     (until date)        (until date)      (until date)           (until date)

 

 

_________________________________________________________________________________      _________________________

Physician/Health Provider                                                                                                                             Date                                         

 

Address ______________________________________________________________________________________________________

                                                (Street)                                      (City)                                        (State)                                       (Zip)

 

Telephone Number _____________________________

 

 

Accepted by Local Health Officer: ______________________________________________________     _________________________

                                                                                 (Signature)                                                                                                                                                    (Date)                                         

 

 

 

School Officials:  DO NOT file this form in the cumulative folder. This form MUST be maintained in a separate file and reviewed periodically to insure validity.

 

Mississippi State Department Of Health                                                                              Revised 04-01                                                                                                                        Form No. 122

CERTIFICATE OF MEDICAL EXEMPTION FORM No.122

 

 

PURPOSE

 

To provide documented proof that an individual has a medically recognized valid contraindication to the administration of a specific antigen or vaccine.

 

INSTRUCTIONS

 

1.         The form is available through all county health departments
and private physicians' offices in Mississippi. It is
issued to individuals only if here is a medically valid
contraindication to a specific antigen or vaccine.

 

2.     The physician must describe the medical condition on which
the contraindication is based and indicate the vaccine.

 

3.     List whether the exemption to the antigen or vaccine is
temporary to permanent. Temporary exemptions must be time-
limited, and the date the exemption becomes invalid is to be
listed.

 

4.     The physician documenting the medical exemption must sign and date the form.

 

OFFICE MECHANICS AND FILING

 

The completed and signed form is given to the client to present
to a school or employer. The County Health Department will
submit a copy of the completed form to:

Immunization Program

P.O. Box 1700

Jackson, MS 39215-1700

 

RETENTION

 

Schools: The completed and signed form is to be maintained in a separate file from the cumulative folder and reviewed periodically to ensure validity.