Immunization Exemption Form printable pdf download

Immunization Exemption Form

(Relitious, Good Cause and Medical)

Amended Substitute Senate Bill No.282, Ohio Revised Code

Sections 3313.671, part (3) and (4)

Section 3313.671, part (3): A pupil who presents a written statement of his parent or guardian

objects to the immunization for good cause, including religious convictions, is not required to be

immunized.

Section 3313.671, part (4): A child whose physician certified in writing that such immunization

against any disease is medically contraindicated is not required to be immunized against that

disease. This section does not limit or impair the right of the board of education of a city,

exempted village or local school district to make and enforce the rules to secure immunization

against poliomyelitis, rubeola, rubella, diphtheria, pertussis, and tetanus for the pupils under its

jurisdiction.

I, the parent or guardian of the below named child, hereby object to the immunization(s) listed

for the following reasons: (please check and identify the required immunizations and the number

of doses that you are refusing)

_____ Polio (dose #_____)

_____ Diptheria/Tentanus/Pertussis (Tdap) (dose # _____)

_____ Measles/Mumps/Rubella (MMR) (dose # _____)

_____ Hepatitis B (dose # _____)

_____ Varicella (Chicken Pox) (dose # _____)

Child’s Name: __________________________ Grade: ______ School: ____________

Religious: (List the name of the denomination) _________________________________

Good Cause: (please explain) _______________________________________________

_______________________________________________________________________

Medical Reason: You must have a signed statement from your physician stating the condition

and attach it to this form.

I further understand that during the course of an outbreak of any of the aforementioned vaccine

preventable diseases, which the student named here is subject to exclusion from school for the

duration of the outbreak. This action is necessary not only to protect the student, but the

remainder of the students and faculty of the school.

Parent/Guardian’s Signature: _________________________________ Date: ________

Address: __________________________________________ Phone: ______________

Immunization Education provided by: __________________________ Date: ________

(nurse)

(9/13/10)

Immunization Exemption Form