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OCFSLDSS4433 (Rev. 5/2014) FRONTIER YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICESCHILD IN CARE MEDICAL STATEMENT
To Be Completed By Licensed Physician, Physicians Assistant or Nurse Practitioner
Name
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Indicate the reason for requesting exempt immunizations.
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Fill out the specific immunizations that you wish to be exempt from.
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Who needs exempt immunizations?
01
Individuals who have medical conditions or allergies that prevent them from receiving certain immunizations.
02
Children who have proof of previous vaccinations that provide adequate protection.
03
People who possess valid religious or philosophical beliefs against immunizations.
04
Individuals who have received medical advice against specific immunizations.
05
Patients undergoing specific medical treatments or procedures that may interact negatively with immunizations.
06
Individuals who have documented contraindications to certain vaccines as determined by the medical community.
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What is exempt immunizations?
Exempt immunizations refer to vaccinations that an individual is not required to receive based on medical, religious, or personal beliefs.
Who is required to file exempt immunizations?
Parents or guardians of children who are not immunized due to a medical, religious, or personal belief exemption are required to file exempt immunizations.
How to fill out exempt immunizations?
Exempt immunizations can be filled out by providing the necessary information on a form provided by the relevant authority, such as a school or healthcare provider.
What is the purpose of exempt immunizations?
The purpose of exempt immunizations is to allow individuals to opt out of receiving certain vaccinations based on medical, religious, or personal beliefs.
What information must be reported on exempt immunizations?
The information that must be reported on exempt immunizations typically includes the individual's name, date of birth, reason for exemption, and any supporting documentation.
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