Student Medical Exemption Request for Influenza Vaccination USC Influenza Vaccination Policy USC students are required to submit proof of receipt of influenza vaccination. Students can request an exemption if they cannot receive the vaccine because of a medical contraindication. A list of established medical contraindications to vaccination can be found on the Centers for Disease Control and Prevention (CDC) website at https://www.cdc.gov/flu/professionals/vaccination/vaccine_safety.htm.
Patient Full Name:
Date of Birth:
USC ID# (10 digits):
The patient identified above has a medical contraindication to the influenza vaccine. This contraindication is
Permanent
Temporary
If temporary please indicate expiration of the medical exemption: Health Care Provider’s Name (please print): MD, DO, PA or NP (please circle) License #: Address:
Telephone number: Practitioner Name/ Stamp (If available): Signature of Authorized HCP:
Date:
I understand this Medical Exemption Request Form and have had the opportunity to ask questions about it. I verify the truth and accuracy of my statements in this Medical Exemption Request Form and acknowledge that declining vaccination may place me at greater risk of becoming ill with influenza. If the medical exemption is temporary, I agree to submit the proper documentation showing proof of required immunization once the medical exemption has expired. Student Signature:
FOR USE BY USC STUDENT HEALTH STAFF ONLY Date Received: Date Approved: Date Denied: Reviewer Name (Print): Reviewer Signature: 101623 MEDEXFLUV_STU
V: 10/16/23