Date: 7/2021

Vaccination Exemption Request Form

Students may request an exemption from Inova’s vaccination requirement for medical or religious
reasons. Inova affiliated schools will assume all responsibility for the following Inova’s vaccine
exemption policy as outlined below.

Medical Exemptions:

 May be granted on permanent bases if a licensed physician, licensed physician’s assistant,

licensed nurse practitioner, or licensed midwife (caring for a pregnant student) certifies in
writing that such vaccination may be detrimental to the student’s health or is otherwise
medically contraindicated. Must include a statement indicating which vaccine may be
detrimental, including an explanation of the valid medical basis for such determination, and
the length of time for which it may be detrimental.
 May be granted on a temporary basis up to the point when the condition supporting an
exemption is expected to resolve or expire per medical providers instruction; If a student
feels a continuation of a temporary exemption is needed, they must submit a new Vaccine
Exemption Request Form along with an updated note from their provider. Once the
temporary exemption as expired, the student will be expected to comply with the vaccine
requirements outlined in Inova’s Immunization Program Policy.

Religious Exemptions:

 A note from your religious affiliate must describe with specificity the sincerely held religious
belief, practice, or observance that guides the objection to immunization.
 Will not be granted when opposition to the immunization is medical, scientific, political,
philosophical, ethical, or otherwise secular rather than religious in nature.
 May require additional supporting documentation.

A complete submission for vaccination exemption must include both the Vaccination Exemption
Request Form and any supporting documentation described above. Exemption requests will not be
reviewed if incomplete documentation is submitted. Complete submissions will be reviewed and
evaluated by affiliated school to determine if they will be granted.

Student will be notified by school representative whether their exemption request was approved. If
an exemption is granted, the student may be required to comply with additional safety protocols, in
order to protect the health and safety of our team members and patients.

To Request a Medical or Religious Exemption:

Please submit the completed Vaccination Exemption Request Form along with supporting
documentation outlined above and email to affiliate school point of contact.

July 2, 2021 inova.org

 Vaccination Exemption Request Form

I, __________________________________, am requesting exemption for the following vaccination(s):

□ Influenza* □ MMR (measles-mumps-rubella) □ Varicella (chicken pox) □ Tdap (pertussis)

□ COVID-19* □ Meningococcal □ Hepatitis B

*If I am approved for an exemption from the influenza or COVID-19 vaccination, I will be required to wear a
surgical mask when I am at any Inova facility. If I am approved for an exemption from the COVID-19
vaccination, I may also be required to engage in physical distancing protocols and abide by such other
requirements that Inova may now or in the future require.

I understand that by not receiving the influenza or COVID-19 vaccination, I may have an increased risk of
contracting either virus or its related complications. Accordingly, if I contract either virus, I understand that
there could be life-threatening consequences to my own health and the health of those with whom I have
contact, including any patients, team members, or my family and community.

Medical Exemption Request

I request a medical exemption for the following reason:
□ Documented allergy to the following component of the vaccine
□ History of the following medical condition contraindicates vaccination
□ Documented anaphylactic allergic reaction to the vaccine
□ Documentation of the following severe adverse effect to the vaccine
□ Current pregnancy or breast feeding.
A letter from your private physician or medical professional on his/her professional letterhead
documenting your exact medical contraindication(s) is attached. □ Yes

Religious Exemption Request

I request a religious exemption:
□ Reason for religious exemption
A letter from your clergy/religious leader on his/her professional letterhead affirming consistency with
prior vaccination history is attached. □ Yes

I am a: □ Student

Signature: Date: ______________

Printed Name: Email Address:
Phone Number:
School/Company/Affiliation (for non-employees):

Submit completed Vaccination Exemption Request Form and required documentation must be
sent to school coordinator and kept on file with all other required back up documentation to the
Inova required Documentation of Compliance.

July 2, 2021
 Vaccination Exemption Form

Name: ____________________________________ Email: __________________________________

I refuse to be vaccinated as recommended. I understand that my refusal is against medical advice and I
may be refused to participate in a clinical rotation. I know that I can change my mind at any time and ask
to be vaccinated.

 MMR (Measles, Mumps, Rubella) 

 Varicella (Chicken Pox) 
 Hepatitis B (Hep B) 
 Tdap (Tetanus, Diphtheria, Pertussis) 
 Polio (IPV) 
 Influenza 
 COVID 19 

 I request a religious exemption from ______________________________ vaccination.

 I request a medical exemption from _______________________________ vaccination.

I understand that refusing a vaccination may have consequences which includes risk of illness and/or
getting a disease that the vaccine prevents. That, I may spread the disease to other people including
children.

I also understand that if I am granted an exemption for the influenza vaccine, I must wear a surgical mask
at all times when I am in direct contact with, or within 6 feet of, any patient for the duration of the flu
season. Failure to do so will result in disciplinary action up to and including failure of the clinical
component of the course.

I understand that this form must be completed and uploaded to Castlebranch and I should place a copy of
this form in my clinical portfolio.

__________________________________________ ___________________
Student signature (required) Date

Physician Certification of Contraindication

I certify that my patient should not be vaccinated against ______________________ due to the reasons
described below:
_____________________________________________________________________________________
_____________________________________________________________________________________

__________________________________________ ___________________
Physician signature (required) Date

___________________________________________ ____________________
Physician printed name Phone #