Policy Details

5141.3 FORM 1 Medical Exemption Form

5141.3
FORM 1

STUDENTS

MEDICAL EXEMPTION FORM

Children with medical exemptions shall be permitted to attend school except in the case of a vaccine-preventable disease outbreak in the school. All susceptible students will be excluded from school based on public health officials' determination that the school is a primary site for disease exposure, transmission and spread into the community. Students excluded from school for this reason will not be able to return to school until (1) the danger of the outbreak has passed as determined by public health officials, 92) the student becomes ill with the disease and completely recovers, or (3) the student is immunized. For example, for measles the complete incubation period is 18 days from the onset of symptoms for the last case in the community. Outbreaks like measles may last for several months.

According to State statutes (Connection General Statutes Sections 19a-7f and 10-204a), no child may be admitted to school without proof of immunization or a statement of exemption. Parents or guardians seeking an exemption on the basis that a give immunization is medically contraindicated should attach to this form a statement signed by their physician stating that in the physician's opinion, such immunization is medically contraindicated and why it is contraindicated (e.g., hypersensitivity to a vaccine component, demonstrated reaction to vaccine, et.). In addition, the parents/guardians should complete the following statement and return it to the school nurse.

To Whom It May Concern:

As the parent(s)/guardian(s) of ____________________________________________________.

(Name of Student)

I/we are submitting the enclosed documentation from a physician that immunization of this child is medically contraindicated. Therefore, this child is exempt from receiving the required immunization as specified by the physician, and shall be permitted to attend school except in the case of a vaccine-preventable disease outbreak in the school.

_________________________________ ___________________

Signature of Parent(s)/Guardian(s) Date

_________________________________ ___________________

Signature of Parent(s)/Guardian(s) Date

_____________________________________________________________

Address

_____________________________________________________________

Telephone #

Litchfield Board of Education

Form adopted: November 30, 2011

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