Arizona schools, preschools and child care facilities must keep this ADHS form on file to exempt a child from immunization requirements for medical reasons. It documents either that the child's health may be adversely affected, temporarily or permanently, by one or more required doses, or that the child has lab evidence of immunity or a documented history of disease.
A licensed physician or registered nurse practitioner prints their name, signs, dates, lists each exempted vaccine with its reason, and marks the exemption permanent or temporary with an end date. The parent or guardian signs an acknowledgement section below.
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A licensed physician or a registered nurse practitioner. The form is the official ADHS format these clinicians use to document a medical exemption from school, preschool or child care immunization requirements. Each exempted vaccine is listed with its reason, and the clinician marks the exemption permanent or temporary with an end date.
Yes. The same PDF contains the English form on page 1 and the Spanish Formulario de Exención por Razones Médicas on page 2. Both versions carry the same fields for the clinician, the vaccines and reasons, the permanent or temporary designation, and the parent acknowledgement.