Form 139 Imm - Medical Exemption Request - Mississippi State Department Of Health printable pdf download

Medical Exemption Request

INSTRUCTIONS

The child’s pediatrician, family physician or internist licensed in Mississippi must complete and submit this

•

form to the District Health Officer where the child will be attending school.

The District Health Officer will complete the Medical Exemption Form 122 and return it via mail to the

•

physician and/or parent at the addresses indicated below.

Date of Request: ____________________

Name of Child: __________________________________________________ Date of Birth: __________________

Last

First

Name of Parent: _______________________________________________________________________________

Last

First

Address: ______________________________________________________________________________ _______

Street

City

State

Zip

Indicate the exemption status for each vaccine in the table below (an exemption status is required for each vaccine):

Vaccine

Mark Permanent, Temporary or No Exemption

Expiration Date if Temporary

DTaP

Hepatitis B

*Hib

IPV

MMR

*Pneumococcal

**Tdap

Varicella

*For child care only

**For 7

grade entry only

Indicate reason for medical exemption (use additional sheets if needed):

_____________________________________________________________________________________________

Print name of child’s pediatrician/family

physician/Internist licensed in MS:

Address: _____________________________________________________________________________________

Street

City

State

Zip

Telephone Number: ____________________________________________________________________________

I declare that:

The physical condition of this child to be such that the vaccination(s) specified on this form would endanger their

•

life or health and outweighs the risks of death or disability from the vaccine preventable disease.

Signature

I have discussed the benefits and risks of immunizations with the parent/guardian as a condition for exemption.

•

I have informed the parent/guardian that if any vaccine-preventable diseases for which the child has not been

•

adequately immunized are occurring in or threatening to occur in the community, the child will, for the safety and

benefit of him/herself and other children, be excluded from daycare/ school until the infectious disease is no

longer present or is no longer a threat to the safety and welfare of the child or other children in the

daycare/school.

Signature of child’s pediatrician/family physician/internist licensed in MS: ______________________________________

Mississippi Medical License Number: ______________________________ NPI #: _________________________________

This document should be submitted to the District Health Officer located in the district where the child will be attending

school. A list of District Health Officers can be found at

Form 139 IMM

Mississippi State Department of Health

Revised 08/06/2015

Request

Form 139 Imm - Medical Exemption Request - Mississippi State Department Of Health

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