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Arizona vaccine exemption form 2023

Form arizona immunization 2025

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The document is a Personal Beliefs Exemption Form from the Arizona Department of Health Services, allowing parents to exempt their children from required vaccinations for school attendance based on personal beliefs. It outlines the risks associated with not vaccinating against various diseases, including diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, hepatitis B, varicella, and meningococcal disease. Parents must acknowledge these risks by initialing next to each disease and provide their child's information along with a signature.

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Click ‘Get Form’ to open the Arizona Immunization Exemption Form in the editor.
Begin by filling in your child's name and date of birth at the top of the form. This information is essential for identifying your child.
For each vaccine listed, place an 'X' in the box next to the disease you wish to exempt your child from. Ensure you read the associated risks carefully.
After marking each exemption, provide your initials and the date in the designated fields on the right side of each section. This confirms that you understand the implications of not vaccinating.
At the bottom of the form, sign as a parent or guardian and include today's date. This finalizes your request for exemption based on personal beliefs.

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How to submit immunization records to ASU?

Step 1: Log into Health Portal. . Step 2: Select Medical Clearances on the left. Step 3: Enter Measles/M.M.R. Information. Step 4: Upload Immunization Record. Step 5: Allow 3 business days for review and processing.

Can I get a copy of my immunization records online on mychart?

Go to My Record Health Summary and select the Immunizations tab. You can see the immunizations youve received and the dates on which you received them. Click the immunization name to learn more. If your immunizations are not up to date, please docHub out to your clinic directly to have your information updated.

How to write a vaccination exemption letter?

Please initial next to each of the statements below: I request a reasonable accommodation due to my sincere religious beliefs. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from the City to the required vaccinations.

How to document immunizations?

All vaccines administered should be fully documented in the patients permanent medical record. Health care providers who administer vaccines that are covered by the National Vaccine Injury Compensation Program are required by law to ensure the permanent medical record of the recipient indicates: Date of administration.

How to write a vaccine exemption letter?

I request a reasonable accommodation due to my sincere religious beliefs. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from the City to the required vaccinations.

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How to write an exemption letter?

Overall, among adults aged 18 years who did not get a 202324 COVID-19 vaccine, the most commonly reported reasons for not getting one were: concern about serious/unknown side effects (39.7%), lack of concern about getting sick (33.6%), belief that the vaccine cant prevent infection (25.9%), not trusting the