Hospital Letter Head Blank Form PDF Details

The Hospital Letter Head form serves a critical function within the framework of public health and legal compliance for educational institutions. Created by University Health Services, it specifically addresses the requirements of the College and University Student Vaccination Act, showcasing a structured approach for students who seek exemption from mandatory vaccines. Notably, it encompasses spaces for critical information, including the student's name, date of birth, and contact details. This document thoughtfully integrates declarations for both medical and religious, or other, exemptions, necessitating signatures from a physician for the former and the student or their guardian for the latter. Furthermore, it emphasizes informed consent, as it requires the acknowledgment of having received and understood information regarding the risks and benefits of the meningococcal vaccine. This clear delineation assures that the decision to opt for exemption is well-informed. Guidance is provided for the return of the completed form, directing it specifically to the Student Coordinator at University Health Services, Thomas Jefferson University Hospital, underlining the form’s significant role in public health within the collegiate environment. This careful balance between health safety requirements and personal or medical exemption rights illustrates the intricate nature of health policies in educational settings.

QuestionAnswer
Form NameHospital Letter Head Blank Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesjefferson county al letterhead pdf, jefferson letterhead template, thomas hospital letterhead, jefferson hospital letterhead template

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University Health Services

T 215.955.6835 F 215.923.5778

jeffuhs@jeffersonhospital.org

STATEMENT OF EXEMPTION TO COLLEGE AND UNIVERSITY STUDENT VACCINATION ACT

Student’s name _______________________________________ Date of Birth ______________

Parent or Guardian name (if under 18) ____________________________________________________

Address ____________________________________________________________________________

Telephone ( ) _____________________

I have been given a copy and have read, or have had explained to me, the information in the Meningococcal Vaccine Information Statement for meningococcal disease. I have had a chance to ask questions that were answered to my satisfaction. I believe that I understand the benefits and risks of the vaccine required. However, I am requesting exemption from Senate Bill No. 955, the College and University Student Vaccination Act.

Medical Exemption

The physical condition of the above named student is such that immunization would endanger life or health.

Signed _____________________________________________

Date __________________

(Physician signature required)

 

Religious or Other Exemption

I, ______________________________________, adhere to a religious belief or have another belief

(printed name)

that is opposed to such immunizations. State your reason for requesting a religious or other exemption.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Signed _____________________________________________

Date ___________________

(Student signature or Parent/Guardian signature)

 

Please return this form to:

Attention: Student Coordinator

 

University Health Services

Thomas Jefferson University Hospital

833 Chestnut Street, Suite 205

Philadelphia, PA 19107

833 Chestnut Street, Suite 205, Philadelphia, PA 19107

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