Vaccine Medical Exemption Form for Internships/Externships/Clinicals with Healthcare Partners

Your Information

Applicant Name

CWI ID Number

DOB (YYYY-MM-DD)

CWI Email Address

Exemption Request Information

Please provide the information requested below. Please provide as much information as possible regarding the reason you are requesting your medical exemption. Keep in mind that your exemption request will be evaluated based solely on the information you provide below, the requred Healthcare Provider Form, and any other documentation you provide.

What academic program are you completing a clinical rotation, externship, or field placement for?(Required) This field is required.

Which specific vaccine requirement(s) are you requesting an exemption from? (You must list specific vaccines or requirements)(Required) This field is required.

Please provide a description of the physical condition of the student or medical circumstances relating to the individual that necessitates the request for a vaccine exemption. Please state, with sufficient detail for independent medical review, the specific nature and probable duration of the medical condition or circumstances that contraindicate vaccination with the specified vaccine.(Required) This field is required.

An exemption from a Healthcare Institutions' vaccine requirement for medical reasons will be considered if the student provides a written certification by a licensed, treating medical provider for one or more of the following reasons. Please select all reasons that apply, and note the required documentation for each:(Required)

I experience an applicable CDC contraindication for the specified vaccine (You must provide the Healthcare Provider Form detailing the specific contraindication, and applicable medical records or documentation) I experience an applicable contraindication found in the manufacturer’s package insert for the specified vaccine (You must provide the Healthcare Provider Form detailing the specific contraindication, the the provision of the package insert, and applicable medical records or documentation) I have a physical condition or medical circumstances such that immunization is not considered safe (You must provide the Healthcare Provider Form, as well as medical records or documentation indicating the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization with the specified vaccine) I am pregnant or nursing (Must provide confirmation from a provider that you are pregnant or nursing, and the Healthcare Provider Form, which must indicate their agreement that you should receive an exemption from vaccination, and the period of time for which they support this exemption)

You must make at least one selection.

Certification(Required)

I certify that the information I am submitting in support of my request for a vaccine exemption is complete and accurate to the best of my knowledge, and I understand that any intentional misrepresentation contained in this request may result in disciplinary action, up to and including expulsion from CWI. I also understand that my request for a vaccine exemption may not be granted if it creates an undue hardship for program participants or the Healthcare Institution, is not reasonable, poses a direct threat to the health and/or safety of others or me in the working or learning environment, materially alters the course or curriculum as determined by CWI at its discretion, or is otherwise not approved by the Healthcare Institution.

This field is required.

By typing my full name below to digitally sign this form, I agree to allow CWI to share this form and any related documentation to CWI’s educational program partners as a condition of participation in my program.(Required) This field is required.

Required Documentation

For all applications, you are required to submit a completed Healthcare Provider Form, and appropriate medical records (as detailed above). If you fail to attach required documentation your request for a medical exemption will not be considered. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Your Information

Exemption Request Information

Required Documentation

Submission