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How do I fill this out?

To fill out this medical exemption form, you'll need to gather specific information and follow the guidelines provided. Ensure you consult a licensed physician who can certify the exemption. Detailed instructions will be provided in the next section.

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How to fill out the Immunization-Related Medical Exemptions for School Children?

  1. 1

    Consult with a licensed physician.

  2. 2

    Provide details on the immunization that is detrimental to the child's health.

  3. 3

    Follow the NYSDOH guidelines for required information.

  4. 4

    Complete the medical exemption form.

  5. 5

    Submit the form to the child's school.

Who needs the Immunization-Related Medical Exemptions for School Children?

  1. 1

    Parents of children with medical contraindications to certain vaccinations.

  2. 2

    Health care practitioners certifying immunization exemptions.

  3. 3

    School administrators managing student immunization records.

  4. 4

    Public health officials ensuring compliance with NYS Public Health Law.

  5. 5

    Legal advisors assisting with medical exemption cases.

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What are the instructions for submitting this form?

Submit the medical exemption form to the child's school by providing the signed document from a licensed physician. Ensure the exemption is duly certified with reasons specified. Forms can be submitted via email, fax, or in person to the school's administration office. It is advisable to retain a copy of the form for your records.

What are the important dates for this form in 2024 and 2025?

Important submission dates for medical exemption forms coincide with school enrollment periods. Ensure forms are submitted before the start of the school year for 2024 and 2025.

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What is the purpose of this form?

The purpose of this form is to provide a standardized method for certifying medical exemptions to immunization requirements for school-aged children in New York State. It ensures that exemptions are documented based on current accepted medical practices and are only granted for valid medical reasons. This form helps protect public health while accommodating children with legitimate medical contraindications to vaccinations.

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Tell me about this form and its components and fields line-by-line.

This form contains fields for detailed medical information required for filing an immunization-related medical exemption.
fields
  • 1. Medical Exemption Certification: Certification by a licensed physician that an immunization is detrimental to the child's health.
  • 2. Immunization Details: Specific immunization detrimental to the child's health, reasons, and duration of contraindication.
  • 3. Physician Information: Licensed physician's contact information and signature.
  • 4. Parental Responsibility: Parental or guardian acknowledgment and responsibility for submitting the form to the school.

What happens if I fail to submit this form?

Failure to submit this form may result in the child's exclusion from school due to non-compliance with immunization requirements.

  • Missed School: The child may be excluded from attending school.
  • Legal Non-Compliance: Failure to adhere to NYS Public Health Law requirements.
  • Health Risk: Potential health risks to the child and others.

How do I know when to use this form?

Use this form when a child has a medical contraindication to a required immunization.
fields
  • 1. Medical Contraindication: When a physician certifies that a vaccine is harmful to the child's health.
  • 2. School Enrollment: During the enrollment process if the child cannot receive required vaccines.
  • 3. Medical Updates: When updated medical information requires changes to immunization status.

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Immunization-Related Medical Exemptions for School Children

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