OSDH Form 216-A "Certificate of Exemption" - Oklahoma

What Is OSDH Form 216-A?

This is a legal form that was released by the Oklahoma State Department of Health - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Oklahoma State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of OSDH Form 216-A by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 216-A "Certificate of Exemption" - Oklahoma

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CERTIFICATE OF EXEMPTION
Please read instructions on the reverse of this certificate before completing.
All entries must be legible or form will be returned. Please print unless signature is required.
______________________________
______________________
________________
_______________________________________________
Name of Child (Last, First, MI)
Birth Date
Birth State
Birth Country
__________________________________________
___________________________________
___________________________________
Parent's Street Address
Parent or Guardian's Name
Mother's Maiden Name
______________________________
__________________
__________________________
_____________________________
Parent Phone Number
State
County
City
___________________
__________________
________________________________________________
________________
_____________
Name of School, Child Care Facility or Head Start
School District
School Year
School Grade
Facility Phone Number
Ethnicity (select 1):
Race (select up to 3):
Child's Gender:
Male
Hispanic
Not Hispanic
Alaskan Native
Asian
Black or
Native Hawaiian or
White Other
Female
or Latino
or American Indian
African American
Pacific Islander
or Latino
TYPE OF EXEMPTION
(Complete either section 1, 2 or 3 and sections 4 & 5)
1.
MEDICAL CONTRAINDICATION:
I hereby certify that the immunization(s) specified below are medically contraindicated for the above named child.
_______________________________________________________
________________________________________________________
Immunization(s)
State the condition that would endanger the life or health of the child.
____________________________________________
_______________________________________________________
Printed name of Physician
Signature of Physician
_________________________________________________ _______________________________________________________
Address of Physician
Phone number of Physician
RELIGIOUS OBJECTION:
2.
I hereby certify that immunization is contrary to the teachings of the above named child’s religion.
___________________________________________________
___________________________________________________
Printed name of Religious Leader or Parent/Guardian
Signature of Religious Leader or Parent/Guardian
3.
PERSONAL OBJECTION:
I hereby certify that immunization is contrary to my beliefs. As the parent or legal guardian of the above named child, I request an
exemption to the immunization requirements for School, Child Care Facility or Head Start attendance. I have written a brief summary
of my objections in the space provided below. I understand that lost records are not grounds for an exemption.
REQUIRED: Summary of Objections: (Limited to 600 characters.)
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
4.
Please check which immunizations this exemption applies to:
DTaP/Td/Tdap
Hib
Polio
(Diphtheria, Tetanus & Pertussis)
(Haemophilus Influenzae type B)
Hepatitis A
MMR
Varicella (Chickenpox)
(Measles, Mumps and Rubella)
Hepatitis B
All
Pneumococcal
5.
Acknowledgement
I understand that in the event of a disease outbreak in the School, Child Care Facility or Head Start, my child may have to be excluded
for his/her protection and for the protection of the other children in the School, Child Care Facility or Head Start.
_________________________________________________
________________________________________________ ____________________
Printed name of Parent/Guardian
Signature of Parent/Guardian
Date
ATTENTION: PARENT/GUARDIAN – This form is to be submitted to the School, Child Care Facility or Head Start.
This section reserved for use by OSDH.
The School, Child Care Facility or Head Start should keep a copy of this form and mail the original to:
Oklahoma State Department of Health
Immunization Service
123 Robert S Kerr, Suite 1702
Oklahoma City, Oklahoma 73102-6406
ODH Form 216-A (Revised 07/21)
For Questions Call: 405-426-8580
__________________ ______
Oklahoma State Department of Health
For forms, visit:
http://imm.health.ok.gov
CERTIFICATE OF EXEMPTION
Please read instructions on the reverse of this certificate before completing.
All entries must be legible or form will be returned. Please print unless signature is required.
______________________________
______________________
________________
_______________________________________________
Name of Child (Last, First, MI)
Birth Date
Birth State
Birth Country
__________________________________________
___________________________________
___________________________________
Parent's Street Address
Parent or Guardian's Name
Mother's Maiden Name
______________________________
__________________
__________________________
_____________________________
Parent Phone Number
State
County
City
___________________
__________________
________________________________________________
________________
_____________
Name of School, Child Care Facility or Head Start
School District
School Year
School Grade
Facility Phone Number
Ethnicity (select 1):
Race (select up to 3):
Child's Gender:
Male
Hispanic
Not Hispanic
Alaskan Native
Asian
Black or
Native Hawaiian or
White Other
Female
or Latino
or American Indian
African American
Pacific Islander
or Latino
TYPE OF EXEMPTION
(Complete either section 1, 2 or 3 and sections 4 & 5)
1.
MEDICAL CONTRAINDICATION:
I hereby certify that the immunization(s) specified below are medically contraindicated for the above named child.
_______________________________________________________
________________________________________________________
Immunization(s)
State the condition that would endanger the life or health of the child.
____________________________________________
_______________________________________________________
Printed name of Physician
Signature of Physician
_________________________________________________ _______________________________________________________
Address of Physician
Phone number of Physician
RELIGIOUS OBJECTION:
2.
I hereby certify that immunization is contrary to the teachings of the above named child’s religion.
___________________________________________________
___________________________________________________
Printed name of Religious Leader or Parent/Guardian
Signature of Religious Leader or Parent/Guardian
3.
PERSONAL OBJECTION:
I hereby certify that immunization is contrary to my beliefs. As the parent or legal guardian of the above named child, I request an
exemption to the immunization requirements for School, Child Care Facility or Head Start attendance. I have written a brief summary
of my objections in the space provided below. I understand that lost records are not grounds for an exemption.
REQUIRED: Summary of Objections: (Limited to 600 characters.)
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
4.
Please check which immunizations this exemption applies to:
DTaP/Td/Tdap
Hib
Polio
(Diphtheria, Tetanus & Pertussis)
(Haemophilus Influenzae type B)
Hepatitis A
MMR
Varicella (Chickenpox)
(Measles, Mumps and Rubella)
Hepatitis B
All
Pneumococcal
5.
Acknowledgement
I understand that in the event of a disease outbreak in the School, Child Care Facility or Head Start, my child may have to be excluded
for his/her protection and for the protection of the other children in the School, Child Care Facility or Head Start.
_________________________________________________
________________________________________________ ____________________
Printed name of Parent/Guardian
Signature of Parent/Guardian
Date
ATTENTION: PARENT/GUARDIAN – This form is to be submitted to the School, Child Care Facility or Head Start.
This section reserved for use by OSDH.
The School, Child Care Facility or Head Start should keep a copy of this form and mail the original to:
Oklahoma State Department of Health
Immunization Service
123 Robert S Kerr, Suite 1702
Oklahoma City, Oklahoma 73102-6406
ODH Form 216-A (Revised 07/21)
For Questions Call: 405-426-8580
__________________ ______
Oklahoma State Department of Health
For forms, visit:
http://imm.health.ok.gov
INSTRUCTIONS FOR COMPLETING THE
CERTIFICATE OF EXEMPTION
Oklahoma law requires that parents of all children attending School, Child Care Facilities, and Head
Start in this state submit acceptable evidence of adequate immunization. Such evidence is required
before the child is allowed to enter or attend School, Child Care or Head Start. Children with specific
medical contraindications to any or all immunizations may be allowed to attend if the medical reason
is stated and this statement is signed by a licensed physician and submitted to the School, Child Care
Facility or Head Start. Children whose parents have objections to immunizations based on religious
teachings or personal beliefs can also apply for an exemption.
Copies of immunization records and any Certificate of Exemption must be on file with the School,
Child Care Facility or Head Start and available for review.
Children enrolled in School, Child Care or Head Start.
FORM REQUIRED:
Children not enrolled in School, Child Care or Head Start.
FORM NOT REQUIRED:
This form must be appropriately completed and signed or it will be denied.
This form is to be submitted by the parent, to the School, Child Care Facility or Head Start.
The School, Child Care Facility or Head Start will submit the form to Immunization Service.
Forms submitted by the Parent/Guardian will not be considered.
LOST IMMUNIZATION RECORDS
Lost immunizations records are not grounds for an exemption to the Oklahoma Law. Parents who
have lost their child’s records should be referred to their local health department or family physician.
The nurse or doctor can interpret the past immunization history and provide any needed
immunizations and create a record for the parent that can be submitted to the School, Child Care
Facility or Head Start and transcribed for the student’s record.
EXCLUSION DURING A DISEASE OUTBREAK
A disease outbreak in a School, Child Care Facility or Head Start will very likely result in exposure of
children attending on the basis of an exemption. These children are very likely to be susceptible to
the diseases and therefore may have to be excluded for the duration of any outbreak for their own
health and for the health of the other children. Parents should be informed of this possibility before
signing a Certificate of Exemption.
A completed copy of the Certificate of Exemption must be mailed by the School,
Child Care Facility or Head Start to the Immunization Service to review all exemptions.
Revised 07/06/2021
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