Other Vaccination Waiver Vaccination Waiver Clinical Site Other Vaccination Waiver Form Please enable JavaScript in your browser to complete this form.List the vaccination you are requesting a waiver for:(here after referred to as the vaccine.)Clinical student to complete this section.Name *Date of Birth *Student ID *Date *Contact Phone NumberEmail *Business or personal email is acceptable.Medical documentation needed: Individuals who have a medical condition that would prevent them from being able to receive vaccines must present documentation from their physician/practitioner.Have you had a life-threatening allergic reaction after a dose of the vaccine? *YesNoIf yes, please describe the reaction, provide the vaccine manufacturer and state the approximate date of the vaccine administration. *Signature *Licensed physician/practitioner to complete and sign this section.Physician/Practitioner Statement: The above-named clinical student from St. Clair County Community College is under my care. I have reviewed the vaccine recommendations and request the following medical exemption based on a true medical contraindication as outlined by the CDC:Permanent Exemption related to:Temporary Exemption related to:Permanent Exemption related to: *Severe allergic reaction (e.g., anaphylaxis) after a previous dose of the vaccine.History of anaphylactic reaction to the vaccine ingredient:Temporary Exemption related to: *This individual will be able to receive vaccine on or after (date): *Name of vaccine manufacturer(s) you are exempting student from: *Provider name *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeState & Medical License #: *Phone *Signature *Religious/Spiritual Exemption RequestAre you seeking a Religious/Spiritual exemption request? *YesNoThe clinical site has asked St. Clair County Community College to administer waiver requests on behalf of the clinical site. The clinical site has the final determination of requirements for individuals with a waiver. A waiver may be granted when a clinical student’s sincerely-held religious beliefs preclude vaccination. A religious exemption will not be granted based on a philosophical, moral or conscientious objection.Please identify your sincerely held religious belief, practice or observance that is the basis for your request for an exemption from the clinical site's the vaccine requirement: *Please briefly explain how your sincerely held religious belief, practice or observance conflicts with the clinical site's the vaccine requirement: *Please indicate whether you are opposed to all vaccines, and if not, the religious basis on which you object to the vaccine. *Please provide any additional information that you think might be helpful in reviewing your religious exemption request: *St. Clair County Community College reserves the right to request additional information needed to evaluate your request.Signature *IMPORTANT NOTE: This exemption is only valid for the program length beginning with the 2023-2024 academic year. The college may require an additional request for exemption. As an individual with this exemption, I understand and certify: I will follow clinical site requirements for the unvaccinated individuals working with patients at the site. I will submit to self-isolation or quarantine in my own residence or an alternate location of my choice and follow the directions of the college and clinic regarding monitoring and self-care in any circumstance (1) where there is a reasonable belief that I have been exposed to an individual who has the medical condition associated with the vaccine, (2) when I may be experiencing any symptom(s) consistent with the medical condition associated with the vaccine, or (3) if such time as my symptoms resolve and I may be medically cleared to resume participation in college and clinical activities. I will respond promptly to outreach from the college and provide all requested information to them regarding my contacts with individuals and cooperate with any contact tracing or other information gathering processes designed to identify risks of virus transmission to others. I will follow any additional public health-protective measures, which may evolve based on the overall course of the pandemic, as required by clinic policy. In the event of an outbreak or a threatened outbreak of the medical condition associated with the vaccine, I will comply with any clinic directive that may bar me from participating in college-approved activities on campus. I certify that the information I have provided in connection with this request is accurate and complete and the exemption may be revoked if any false information has been used to request an exemption. I understand that although the college and clinic holds the health and safety of its community as paramount, there is no guarantee that I will not be exposed to or infected with the medical condition associated with the vaccine. I have reviewed the CDC’s information on the benefits of getting the vaccine for which I am requesting a waiver and understand that, as an unvaccinated individual, my physical presence as well as participation and utilization of facilities, services and programs at the clinic may carry heightened risks that cannot be eliminated regardless of the care and reasonable efforts taken to avoid and mitigate those risks. I also understand that I may be at higher risk for severe complications from the medical condition for which I am seeking a waiver, if I have particular conditions identified by the CDC. Despite these risks, I chose not to be vaccinated. I have read and fully understand my obligations as described above and request this exemption related to the vaccine listing at the top of this form. Signature *Date *Submit
