Immunization

Non-Medical Exemption Form

Vaccines are one of the greatest public health achievements of the past century and save an estimated 3 million lives every year. The Colorado Department of Public Health and Environment and Colorado State University Pueblo strongly support vaccination as one of the easiest and most effective tools in preventing diseases that can cause serious illness and even death. For nearly all people, the benefits of preventing disease with a vaccine far outweigh the risks. Declining to follow the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) immunization schedule for number, space and timing of doses, may endanger an unvaccinated individual's health and others who come into contact with them.

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.

Non-Medical Exemption Claimed:

Faculty/Staff/Student Information:

First Name:

Last Name:

NET ID:

Date of Birth:

Sex:

Female Male Other

If Student is under 18 - Parent/Guardian completing this form:

Parent/Guardian First Name:

Parent/Guardian Last Name:

Relationship to student:

Mother Father Legal Guardian

Vaccine Preventable Disease Information

The Information below is to ensure parents/guardians/students are informed about the risks of not vaccinating The SARS-CoV-2 (COVID-19) – Unvaccinated persons may be at increased risk of developing COVID-19 if exposed to this disease. Serious symptoms and effects include difficulty breathing, loss of taste or smell, body aches, and death.

For more information visit: Key Things to Know About COVID-19 Vaccines

Required Vaccine for University Enrollment or Employment

Check if declining required vaccine:

SARS-CoV-2(COVID-19)

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

Statement of Exemption

I am the Faculty/staff /student or the parent/guardian if student is under 18 years of age, and am declining the COVID-19 vaccine(s) indicated above due to a non-medical belief that is opposed to vaccines. The information I have provided on this form is complete and accurate.

I may change my mind at any time and accept the COVID-19 vaccination for myself in the future (or for my child).
I have had to opportunity to review the vaccine information provided by the Colorado Department of Public Health and Environment: Immunization education and Immunize for Good for information on the benefits and risks of vaccines and the diseases they prevent OR
I have had the opportunity to review information about what is in the mRNA based Vaccines (Pfizer and Moderna) and how they work.