<> 1 0 obj Signature of Patient/Parent/Guardian: Please sign here ___________________________Date__________________ RELEASE AND ASSIGNMENT: Complete and mail, fax or email to: Call 1-800-803-7847 for assistance finding a vaccine in your area or to sign up for an ADH clinic. Thiswebsite allows you to submitan application for exemption. b,m*z_z)+ZcDWGJBJmu.ui6]M]iX. Click to download the Medical Exemption Application Form for nursing home workers. Exemptions shall be granted only by the Arkansas Department of Health. NOTE: The person requesting the shot record must be a responsible party on record. An attestation form from Conway (Ark.) Varicella (Chickenpox), 2023-2024 College Immunization Exemption Application %PDF-1.7 Here you will find vaccination recommendations for children, teens, and adults. Pleasecomplete your Immunization Exemption Application, print it,sign it, have it notarized, andreturn itto the Arkansas Department of Health Immunization Section. The form asks. "Getting vaccinated is important," said Dr. Schaffner. Each time you receive an additional dose of COVID-19 vaccine, you will need to obtain a new COVID-19 SMART Health Card to ensure all vaccinations are included on your card and in your QR code. endobj 2 0 obj What conditions could cause someone to be medically exempted from the COVID-19 vaccine? How do I get information about 2022-2023Mass Flu Clinics? HB1977 and SB739 would require employers that mandate vaccinations to provide an exemption process for workers, including requiring them to produce a negative antigen test once a week or proof of. endobj Q: How do I get a copy of my shot record, the shot record of my child, or a child under my guardianship? <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 16 0 R 19 0 R 20 0 R 21 0 R 22 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Arkansas Gov. 12.2.0.180809. Copyright 2017 - 2018 Arkansas Immunization Program. You may already have it. <> When youre done filling out the form, print it and mail it to the Health Insurance Marketplace. We will send you a letter of approval or denial within ten working days of receiving a completed application. What Are the Differences Between the Pfizer and Moderna COVID-19 Vaccines? Q: When are flu shots needed and where do I get them? Getting the COVID-19 Vaccine: What to Expect Before, During, and After Your Appointment, Is the COVID-19 Vaccine Safe for Everyone? Answer:See Immunization Requirements for Daycares and Schools. 2022-2023 Childcare-School Immunization Exemption Application, DTap If youre still having trouble, If you right-click and are still having trouble, you may need to. A physician statement outlining medical reasons for an exemption of a specific immunization is to be submitted to the Medical Director of the Immunization Section with the exemption form. Release of information will be provided only to the custodial parent/guardian or student over 18 years of age who completes this application and according to the notarized signature. endobj While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources. Though some healthcare facilities require healthcare workers to get vaccinations for vaccine-preventable diseases, no state requires vaccines for adults. % You are responsible for retaining the original letter. HIB Pfizer-BioNTech COVID-19 vaccines. All Rights Reserved. The Arkansas Board of Health requires that all children attending childcare facilities and public or private schools in the State of Arkansas be immunized against vaccine-preventable diseases and also requires that all students attending colleges and universities in the State of Arkansas be immunized against measles, mumps, and rubella. Arkansas lawmakers Friday approved requests from three state agencies to implement covid-19 vaccination requirements, with religious and medical exemptions, for employees in facilities that . For information, inquiries, feedback and comments contact us. NH Immunization Reporting Form for NH's 22-23 2022-2023 College Immunization Exemption Application, Nursing Home Flu Policy This website is using a security service to protect itself from online attacks. A medical exemption is due to a patient having a contraindication to the vaccine, meaning getting it could be bad for their health. stream This is a rare but severe condition that causes blood clots. TD (Tetanus, Diphtheria) The Arkansas Department of Health is authorized by Act 999 of 2003 to grant individual exemptions from the immunization requirements. Pneumococcal Conjugate (PCV13) Employees may request an exception to the COVID-19 vaccine due to a physical or mental disorder or condition that limits a major life activity and any other condition recognized as a disability under applicable law including pregnancy, childbirth, or a related medical condition where reasonable accommodation is medically advisable. <> Immunization doesnt just protect the person getting the shot; it protects the entire community. Thank you for using our online Immunization Exemption Application module. Arkansas Immunisation Exemption Application. Here's a breakdown. The updated, or bivalent boosters, target the most recent Omicron subvariants, BA.4 and BA.5, that are more contagious and more resistant than earlier strains of Omicron. Eight requests are for religious reasons and. Vaccines are the safest way to protect you, your children, and your community from a long list of serious and potentially life-threatening illnesses. If your application is not complete, we will send you a checklist showing the reason(s) we were unable to process your application. Office of Performance Management Quality Improvement and Evaluation. % For people who experience this or another adverse event following a shot, the CDC encourages you to report it to the Vaccine Adverse Event Reporting System (VAERS). The Arkansas Department of Health is authorized by Act 999 of 2003 to grant individual exemptions from the immunization requirements. What Happens if You Miss Your 2nd COVID-19 Shot? When you receive a COVID-19 vaccination record from the Arkansas Department of Health or your health care provider and the record is from the state immunization information system, WebIZ, the record will contain your COVID-19 vaccination history and a 2D barcode, commonly known as a QR code. As more businesses continue to enforce vaccine requirements . A vaccine exemption Affidavit is a document that is sworn by you and signed before a notary public (including a notary or a paralegal) in order to establish your request to be exempt from the COVID-19 vaccine. %PDF-1.5 After you have received your approval letter, you are responsible for notifyingthe students daycare, school,college, or university that your exemption request has been approved. "Swearing" the document simply means that you are swearing or declaring that the statements in the document are true. Q: Do I need an appointment at my ADH local health department to get my child their required vaccinations? You need to save the file to your computer before you can open it. k, =ah}/e,'Tb%];CF-Y-Z=ZQAJL\DTZ*^O1Qx[7IY7P'` Y\f" uCW/R{&]{h&.Y-]q7#0rQN;7;3q`mVjyxm$ppTkBzx+x" Wywoa}~@'G PDy3hyHE. Office of Performance Management Quality Improvement and Evaluation, Vaccine plan in response to COVID-19 pandemic, CDC Frequently Asked Questions about COVID-19 Vaccination, Health Equity Strike Team Vaccination Clinics, Johnson & Johnson COVID-19 Vaccine EUA Fact Sheet for Patients, Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Patients, Moderna COVID-19 Vaccine EUAFact Sheet for Patients, Pfizer-BioNTech Pediatric COVID-19 Vaccine Distribution Plan, CDC COVID-19 Vaccination Program Provider Agreement, COVID-19 Vaccine Program Enrollment Instructions, Johnson & Johnson COVID-19 Vaccine EUA Fact Sheet for Healthcare Providers, Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Healthcare Providers, Moderna COVID-19 Vaccine EUAFact Sheet for Healthcare Providers, COVID-19 Information for Healthcare Providers, Arkansas Alzheimers Disease & Related Dementias (AADRD), Blood Pressure (Hypertension) Resources for Patients and the Public, Blood Pressure (Hypertension) Resources for Professionals, Arkansas Heart Attack Registry Participating Hospitals, Arkansas Acute Stroke Care Task Force (ASCTF), Provisionally Designated as Arkansas Stroke Ready Hospitals. Little Rock, AR 72205. Or E-mail us to request the exemption form. Please Click here to download the list of International Travel Physicians who provide immunizations for travelers. Dr. Schaffner recommended meeting with an allergist. Centers for Disease Control and Prevention. 4815 West Markham Street Little Rock, Arkansas 72205-3867 Telephone (501) 661-2000, Arkansas Immunization Exemption Application. 4815 West Markham Street Little Rock, Arkansas 72205-3867 Cell (501) 661-2000 . PLEASE NOTE: The form requires a signature and seal of a Notary Public. Outdated or alternate forms are not allowed. 20-7-109, 6-18-702, 6-60-501 - 504, and 20-78-206. FAX: 501-661-2300 The Centers for Disease Control and Prevention (CDC) breaks down the contraindications and precautions for people getting any of the COVID-19 vaccines. In the near future, the federal Occupational Safety and Health Administration (OSHA) and the North Carolina Division of Occupational Safety and Health (NC OSH) are likely to require most larger employers to adopt a vaccine mandate (see here).Vaccine mandates are lawful, subject only to . 2022-2023 College Immunization Exemption Application, Nursing Home Flu Policy Q:How do I report a possible adverse event after receiving an immunization? Request for Medical Exemption from COVID-19 Vaccine Form . Office of Performance Management Quality Improvement and Evaluation, 2023-2024 Childcare-School Immunization Exemption Application, 2022-2023 Childcare-School Immunization Exemption Application, 2023-2024 College Immunization Exemption Application, 2022-2023 College Immunization Exemption Application, Immunizations Required for AR Daycares & Schools, NH Immunization Reporting Form for NH's 22-23, Recommended Immunizations for Children (Birth through 6 Years), Recommended Immunizations for Preteens and Teens (7-18 Years), Recommended Immunizations for Adults (19 Years and Older) by Age and Medical Condition, Recommended Immunization Schedule for Children and Adolescents aged 18 Years or Younger, Recommended Immunization Schedule for Adults. The information in this story is accurate as of press time. Vaccine-preventable diseases can be very serious, may require hospitalization, or even be deadly - especially in infants and young children. Q. _____ (insert patient's name) is requesting a reasonable accommodation due to a medical condition or disability. A lawsuit has been filed against Conway Regional Health System over religious exemptions and the hospital's COVID-19 vaccine mandate. Answer:Arkansas law requires all students attending Arkansas schools and licensed childcare facilities to be vaccinated against certain diseases, unless an official exemption form is filed.
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