Immunization

Medical Exemption Form

Colorado law C.R.S. § 25-4-902 requires all students attending any school in the state of Colorado to be vaccinated against certain vaccine-preventable diseases (i.e., Measles, Mumps, Rubella), as established by Colorado Board of Health rule 6 CCR 1009-2, unless an exemption is filed. While the Board of Health does not currently require vaccination against COVID-19, Colorado State University Pueblo's COVID-19 Vaccination Policy extends this requirement to the COVID-19 vaccination unless an exemption is filed, and voluntarily adopts the principles described in § 25-4-903, C.R.S. (Exemptions from immunization-rules) for the purposes of the University's COVID-19 Vaccination Policy. This requirement applies to all students, faculty and staff at Colorado State University Pueblo.

Persons with a recorded immunization exemption may be kept out of school or off campus during a disease outbreak; the length of time will vary depending on the type of the disease and the circumstances of the outbreak. Medical exemptions need to be filed only once unless the person's information or school changes.

Patient Information:

First Name:

Last Name:

NET ID:

Date of Birth:

Sex:

Female Male Other

Parent/Guardian completing this form (Only if student is under 18 years):

Parent/Guardian First Name:

Parent/Guardian Last Name:

Relationship to student:

Mother Father Legal Guardian

Required Vaccine for School Entry/Employment

Check vaccine declined:

SARS-CoV-2(COVID-19)

List medical contraindication(s) for each vaccine declined:

Note: By clicking the below submit button, you are accepting the Statement of Exemption and electronically signing this form

Statement of Exemption

The physical condition of the above named person is such that vaccination would endanger their life or health or is medically contraindicated due to other medical conditions. The information I have provided on this form is complete and accurate.