ART 1011 Chapter : Immun Comp Form Rvsd 04 2012
Document Summary
Number: 89- _ _ _ - _ _ _ _ telephone: (_____)__________________ (street/p. o. This must be completed by a physician or health care provider - no attachments accepted or. Tetanus - diphtheria (one dose required within 10 years) Meningitis (one dose of menactra or menveo anytime or a dose of menomune within the past year) Request for immunization exemption: if you request an immunization exemption for medical or personal reasons or due to an inability to locate a specific vaccine, please check the appropriate box and provide the requested information. Medical (physician"s statement required) personal (state reason in space below) shortage (unable to locate vaccine) I have received and reviewed information from the center for disease control and prevention"s (cdc"s) website at http://www. cdc. gov/nip/publications/vis/default. htm regardi ng vaccine chosen not to be vaccinated. If i am not 18 years of age, my parent or legal guardian must sign below.
