Influenza Vaccination
Student Medical Exemption Request Form – Part B
To be completed by requestor’s personal health care provider
Please print legibly.
Patient’s last name:
Patient’s first name :
Last four digits of Social Security #:
Date of birth:
Wheaton Franciscan Healthcare is committed to protecting our patients, health care personnel and the community from
influenza. Our influenza vaccination safety initiative requires students, without sincerely held religious objections or
medical contraindications, to receive an annual influenza vaccine. Your patient is requesting a medical exemption from
receiving the influenza vaccine. Medical exemptions are granted for recognized contraindications.
Guidance for medical contraindications can be obtained from the Center for Disease Control and Prevention publication,
Morbidity and Mortality Weekly Report (MMWR) August 17, 2012/61(32): 613-618, Prevention and Control of Influenza
with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) – United States, 2012-13
Influenza Season. This can be found at the following website: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm
Please clarify your patient’s contraindication(s) to the influenza vaccine:

Previous reaction to influenza vaccine (e.g., hives, difficulty breathing, swelling of tongue or lips)
 The above does not include sensitivity to the vaccine such as an upset stomach or mild to moderate local

reactions such as soreness, redness, itching, or swelling at the injection site.
The above does not include subsequent upper respiratory infection or low-grade or moderate fever following a
prior dose of the vaccine.
Date of reaction:
Description of reaction:

Severe egg allergy



Please note ACIP recommendations:
If patient can eat a lightly cooked egg (e.g., scrambled egg) without reaction then administer vaccine per usual
protocol.
If after eating eggs or egg-containing foods, the patient experiences ONLY hives then administer TIV and observe
for reaction for at least 30 minutes after vaccination.
If a patient experiences cardiovascular change (e.g., hypotension), respiratory distress (e.g., wheezing),
gastrointestinal symptoms (e.g., nausea/vomiting), reaction requiring epinephrine or reaction requiring emergency
medical attention then refer to a physician with expertise in management of allergic conditions for further
evaluation.
Date of reaction:
Description of reaction:

History of Guillain Barre Syndrome (GBS)
Date patient had GBS:

Other
Date:
Description:
Provider’s signature:
Date:
Provider’s name (please print):
Address:
Phone: