KANSAS CERTIFICATE OF IMMUNIZATIONS - FORM B
MEDICAL EXEMPTION
Student Name:_______________________________________________________
Birthdate:____________
Street Address:________________________________________________________________________________
City:___________________________________________
State:_______
Zip Code:________________
Parent/Guardian:_______________________________________________________________________________
Telephone:______________________________
Medical exemption due to
______________________________________________________________________
for the following vaccine(s):
( ) DTaP/DT
( ) Hepatitis A
( ) Tdap/Td
( ) Hepatitis B
( ) Pertussis Only
( ) Pneumococcal Conjugate
( ) Polio
( ) Meningococcal Conjugate
( ) MMR
( ) Varicella
( ) Hib
( ) Human Papillomavirus
( ) Rotavirus
( ) Other:_________________________________
I certify the physical condition of this child to be such that the inoculation(s) specified on this form would
seriously endanger the life or health of this child.
Signature:_______________________________________________________
Date:___________________
PLEASE PRINT
Name:_______________________________________________________________________________________
Street Address:________________________________________________________________________________
City:_______________________________________________
State:______
Zip Code:_____________
Telephone:______________________________
Medical License Number:______________________________________________
State of Licensure:______
A Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.) must complete this affidavit. Annual medical exemptions shall be documented on this form and attached to
the student’s Kansas Certificate of Immunizations (KCI) form. Annual medical exemptions must be completed as long as the medical exemption is warranted.
Rev. 2-05-2009
Kansas Immunization Program
Bureau of Disease Control and Prevention
DIVISION OF HEALTH
1000 SW Jackson, Suite 210, Topeka, Kansas 66612-1274
Phone 785-296-5591
Fax 785-296-6510
Web Site www.kdheks.gov/immunize
For Disease Reporting and Public Health Emergencies: 1-877-427-7317
