This form must be completed by a licensed physician or an advanced practice provider.
Proof: Submitted to school as proof of exemption from required immunization.
Medical exemption: Exemption can last for a maximum of one (1) year, and a new form must be completed annually if medical exemption still applies.
General Contraindications to All Vaccines: Vaccine should not be given.
Vaccine Specific Precautions: Vaccine may be given or held depending on clinical situation.
| Question | Answer |
|---|---|
| Form Name | State Form 54648 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 47 |
| Avg. time to fill out | 8 min |
| Edition | R3 / 8-26 |
| Issuing agency | Indiana Department of Health, Immunization Division |
| Who completes it | A licensed physician or an advanced practice provider |
| Other names | State Form 54648, Form 54648, 54648, Indiana Vaccine Medical Exemption, Vaccine Medical Exemption, Indiana vaccine exemption form |
| Official source | State Form 54648 (R3 / 8-26), Indiana Department of Health |
State Form 54648 isn’t the one you’re looking for?