Vaccination Exemption Process
STUDENTS/Clinical Faculty
Name:
College/University:
Department/Type of Student:
Dates of Rotation:
Vaccine Requesting Exemption: __________________________________________________
I am requesting an exemption from a vaccine. I acknowledge that the vaccination is recommended by the
Centers for Disease Control and Prevention (CDC) for all healthcare personnel to prevent infection. I
understand that my clinical placement site has a mandatory vaccination program, and I am requesting
an exemption.
1. I agree to the above statement.
Yes
No
2. I have a medical condition that prevents me from receiving above vaccine. *
You must attach a signed statement from your physician indicating the contraindication to the
vaccine. You must also attach any supporting documents.
Yes
No
3. I do
not believe in vaccines for religious reason. *
You must submit a statement explaining the religious basis on which you seek this exemption.
Yes
No
*Documentation to support the request for my exemption must be submitted with this form to Alex Maus
([email protected]) and Deana Brown ([email protected]). Upon receipt, the
documentation and exemption request will be reviewed, and approval or denial status will be determined.
The status of the request will be communicated to the student. If denied, you will be required to receive
the vaccine. MUST SUBMIT REQUEST 30 DAYS PRIOR TO THE START OF THE ROTATION.
I understand that I am submitting these records to a third party entity, such as UC Health or University of
Cincinnati. I authorize representatives of these entities to have access to these records for medical and
public health purposes.
Name: Date:
