State Form 54648 PDF Details

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QuestionAnswer
Form NameState Form 54648
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesreligious exemption form indiana, religious exemption vaccination letter indiana, vaccine exemption form indiana, religious exemption vaccination letter for adults indiana

Form Preview Example

VACCINE MEDICAL EXEMPTION

State Form 54648 (4-11)

Indiana State Department of Health, Immunization Division

INSTRUCTIONS: 1. This form for any child in grades K – 12 who is unable to receive a vaccine required for school entry due to a medical contraindication. 2. Complete and sign form. Submitted to school as proof of exemption from required immunization.

Patient Name ____________________________________________________

Date of Birth (month/day/year) ________________

Parent/Guardian Name _____________________________________________

Relationship _____________________________

Street Address _______________________________________________________________________________________________

City _______________________________________ ZIP Code __________ Telephone Number _________________________

General Contraindications to All Vaccines (Vaccine should NOT be given.)

Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component

Hepatitis B (Hep B)

Inactivated poliovirus (IPV)

Meningococcal, conjugate (MCV4)

Diphtheria, tetanus, pertussis (DTaP, Tdap)

Measles, mumps, rubella (MMR)

or Meningococcal, polysaccharide

(MPSV4)

Tetanus, diphtheria (DT, Td)

Varicella (Var)

 

Which vaccine or vaccine component caused reaction? _______________________________________________________________

Type of Clinical Reaction & Date (month, day year) ___________________________________________________________________

Vaccine Specific Contraindications (Vaccine should not be given.)

DTaP or Tdap

Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) not attributable to another identifiable cause

 

within seven (7) days of administration of previous dose of DTP or DTaP

 

 

 

MMR

Pregnancy

Estimated Date of Confinement (EDC): _________________________________ (month, day year)

 

Known severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long

 

term immunosuppressive therapy; or patients with HIV infection who are severely immunocompromised)

 

 

 

Varicella

Pregnancy

Estimated Date of Confinement (EDC): _________________________________ (month, day year)

Substantial suppression of cellular immunity

Vaccine Specific Precautions (Vaccine may be given or held depending on clinical situation.)

DTaP or Tdap

Guillan-Barre syndrome (GBS) within six (6) weeks after a previous dose of tetanus-containing vaccine

 

History of Arthus-type hypersensitivity reaction following a previous dose of tetanus and/or diphtheria toxoid-containing vaccine:

 

defer vaccination until at least ten (10) years have elapsed since the previous dose

 

Progressive or unstable neurologic disorder, uncontrolled seizures or progressive encephalopathy: defer vaccination with DTaP or

 

Tdap until a treatment regiment has been established and the condition has stabilized

 

 

DTaP

Temperature of ≥105F (≥40.5C) within forty-eight (48) hours after vaccination with a previous dose of DTP/DTaP

 

Collapse and shock-like state (i.e.: hypotonic hyporesponsive episode) within forty-eight (48) hours after previous dose of DTP/DTaP

 

Seizure or convulsion within three (3) days after receiving a previous dose of DTP/DTaP

 

Persistent, inconsolable crying lasting three (3) or more hours within forty-eight (48) hours after a previous dose of DTP/DTaP

 

 

MMR

Recent (within eleven (11) months) receipt of antibody-containing blood product (interval depends on product)

 

History of thrombocytopenia or thrombocytopenic purpura

 

 

Varicella

Recent (within eleven (11) months) receipt of antibody-containing blood product (interval depends on product)

 

Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) twenty-four (24) hours before vaccination; if possible, delay

 

resumption of these antiviral drugs for fourteen (14) days after vaccination

 

 

Other Medical Contraindication (Must list vaccine(s) and contraindications individually – continue on back if necessary.)

Vaccine

Specific Contraindication

Please indicate the duration of the medical exemption, and if and when vaccine can be safely administered.

(Exemption can last for a maximum of one (1) year, and a new form must be completed annually if medical exemption still applies.)

Medical exemption is permanent, and will apply for one (1) year from today’s date.

Medical exemption is temporary (<1 year), and resolution is anticipated by ____/____/____

Medical exemption is pregnancy, and Estimated Date of Confinement (EDC) is ____/____/____

Physician Name

____________________________________________________

Physician License Number____________________

Office Address

_____________________________________________________

Telephone ________________________________

Physician Signature _________________________________________________

Date (month, day year) ______________________

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