Ontario's Ministry of Education uses form 3041E when a child, or an individual, at a licensed child care centre or home child care agency needs a medical exemption from the immunization requirements of O. Reg. 137/15 under the Child Care and Early Years Act, 2014. The health professional marks the reason and length of exemption for each disease, and the statement goes to the child care provider.
A regulated health professional completes the Section 2 declaration and signs Section 3 with a registration or licence number; the declaration heading also names a physician or registered nurse (nurse practitioner). The parent, or the individual, fills in Section 1 and names the child care centre or home child care agency.
Download the current version from the source each time; forms change without notice.
Statement of Medical Exemption (Child Care and Early Years Act)
Déclaration d'exemption médicale
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A regulated health professional signs Section 3 and gives a registration or licence number. The Section 2 heading names a physician or registered nurse (nurse practitioner), and the declaration certifies that, for the medical reasons indicated, the child or individual should be exempted from the requirements of O. Reg. 137/15.
No. Form 3041E is the Ministry of Education's statement for licensed child care under the Child Care and Early Years Act, 2014. School immunization exemptions use a separate Ministry of Health form, 4895-64E, under the Immunization of School Pupils Act, which does not list Hib.
No. It is an XFA-based fillable PDF that opens and fills correctly only in Adobe Acrobat or Reader, and the Central Forms Repository warns that older versions such as Adobe Reader XI no longer work. A French version, 3041F, is posted alongside it.