By getting shots on time, you can protect your child and yourself from disease and protect others at home, daycare, school, or work. The form asks. For information regarding mass flu clinics and school flu clinics, please contact your local publichealth unit. To fill out a health coverage exemption application, you'll need to download it onto your computer first. You will then need to include the requested information and return the updated application for processing. Complete and mail, fax or email to: Interim clinical considerations for use of COVID-19 vaccines currently approved or authorized in the United States. Arkansas will implement COVID-19 SMART Health Cards beginning September 14. 2023 University of Arkansas for Medical Sciences, University of Arkansas for Medical Sciences, Blood/Body Fluid Exposure & Needle Sticks. Here you will find vaccination recommendations for children, teens, and adults. The University of Arkansas for Medical Sciences is mandating COVID-19 vaccination for all its employees, non-employees and students. If you dont have the right software installed, youll be sent to a page telling you to download it. 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. 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. 7500 Security Boulevard, Baltimore, MD 21244. The action you just performed triggered the security solution. "Getting vaccinated is important," said Dr. Schaffner. Hepatitis A Some states make it easier to avoid vaccines than others. For information, inquiries, feedback and comments contact us. COVID-19 Mu Variant Named a 'Variant of Interest'Here's What You Need to Know, What To Do if You Have an Allergy to a COVID-19 Vaccine, Pfizer-BioNTech's COVID-19 Vaccine Ingredient List, Booster Recommendations After J&J's Janssen COVID-19 Vaccine. 2023 Open Enrollment is over, but you may still be able to enroll in 2023 health insurance through a Special Enrollment Period. An application requesting an exemption must be submitted for each child or student. The QR code may be scanned into an app on your smartphone and used to verify your COVID-19 vaccination history at places that have a SMART Health Card compatible verifier app, such as airports, business, and large venues. NH Declination Log Colorado Senate Bill 163 requires a person seeking a nonmedical exemption (either religious or personal belief) to submit a certificate of completion of an online educational module or a certificate of nonmedical exemption. For example, one such situation recognized by the CDC as a contraindication to getting a Johnson & Johnson booster vaccine is for those who experience thrombosis with thrombocytopenia syndrome (TTS) after their first J&J shot. Q: How do I get a religious or philosophical exemption for my child regardingtheir required immunizations? The University of Arkansas for Medical Sciences mandates COVID-19 vaccinations for all of its employees, similar to other required va ccinations such as MMR and Influenza. b,m*z_z)+ZcDWGJBJmu.ui6]M]iX. 4 0 obj Vaccine clinics and events may also be available in your area through hospitals, health care providers, or your worksite. However, this might not mean that you can't be vaccinated at all. :V/::Alg However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. All Rights Reserved. Little Rock, AR 72205. The COVID-19 SMART Health Care QR Code is not connected to the WebIZ. 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. Youre ready to start filling it out. Incomplete forms will be returned for completion. stream By getting shots on time, you can protect your child and yourself from disease and protect others at home, daycare, school, or work. The classification is actually pretty narrow. NOTE: You MUST have access to a printer before you start the online application process. 20-7-109, 6-18-702, 6-60-501 - 504, and 20-78-206. What Are Side Effects of COVID-19 Vaccines? This form must also be signed by a Notary . You need to save the file to your computer before you can open it. How Long Does It Take for the COVID-19 Booster To Be Effective? Q:How do I report a possible adverse event after receiving an immunization? % Here's a list of the Comirnaty/Pfizer-BioNTech vaccine ingredients: While we're at it, here's a list of the ingredients in the Moderna COVID-19 vaccine: And the ingredients for the Johnson & Johnson COVID-19 vaccine: For each vaccine, the contraindication is the same: You shouldn't get it if you have had a severe allergic reaction to one of the ingredients in the vaccine. Q:How do I get a medical exemption for my child regarding a required immunization? All fifty states allow immunization exemptions for medical conditions. Q: How do I get a copy of my shot record, the shot record of my child, or a child under my guardianship? To apply, please view the brief Introduction video below. Measles, Mumps, & Rubella What Your Sex Has To Do With COVID-19 Vaccine Side Effects, ShinglesHerpes ZosterInfection May Be Linked to the COVID-19 Vaccine, The FDA Just Authorized Johnson & Johnsons Single-Shot Vaccine for Emergency UseHeres How it Stacks Up, This COVID-19 Vaccine Is the First Plant-based Vaccine for Humans. If you received COVID-19 vaccinations in another state, you may provide your vaccination information to your health care provider for a local health unit and the information will be added to your Arkansas WebIZ record. All rights reserved. FAX: 501-661-2300 Email: immunization.section@arkansas.gov TD (Tetanus, Diphtheria) The Medical Director will decide whether to grant the medical exemption based on the CDC guidelines. NH Immunization Reporting Form for NH's 22-23 Or you can E-mail us or call (501-661-2169) to request the release form be faxed or mailed. NOTE: The person requesting the shot record must be a responsible party on record. As more businesses continue to enforce vaccine requirements . Copyright 2017 - 2018 Arkansas Immunization Program. <> Find out if you qualify for a Special Enrollment Period. 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. Select a location on your computer to save this application on the desktop, in your documents folder, or somewhere else it will be easy to find. When both are completed, you can go to "My Tickets" on ACMS and upload the completed form to your RA ticket. It establishes an immunization goal of 95% of each school's student population and requires . Performance & security by Cloudflare. What Happens if You Miss Your 2nd COVID-19 Shot? Only a valid Immunization Exemption Application will be accepted for the school year. A goal of the Arkansas Department of Health is to control and prevent the spread of these diseases by providing vaccines to local health units in each county and over 500 non-health department facilities in Arkansas. Request for Medical Exemption from COVID-19 Vaccine Form . Hepatitis A 2017 Arkansas Department of Health. The Centers for Disease Control and Prevention (CDC) breaks down the contraindications and precautions for people getting any of the COVID-19 vaccines. There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. )x endobj Answer:Patients should contact the clinic or provider who gave the immunization. If you received COVID-19 vaccinations in another state, you may provide your vaccination information to your health care provider for a local health unit and the information will be added to your Arkansas WebIZ record. Tdap (Tetanus, Diptheria, Pertussis) "For example, if someone had a severe allergic reaction to dose one of the mRNA vaccines, they could complete their series with the Johnson & Johnson vaccine," said Dr. Adalja. Getting the COVID-19 Vaccine: What to Expect Before, During, and After Your Appointment, Is the COVID-19 Vaccine Safe for Everyone? Meningococcal ACWY If your application is not complete, we will send you a checklist showing the reason(s) we were unable to process your application. <> Arkansas Department of Health, "The same is true for those who have known allergies to the ingredients of one of the vaccines.". UAMS Form for Medical Exemption from Covid-19 Vaccination . You have two options: Double-check youre following the download instructions for your web browser. 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. 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. x[mo)aOvVU4IjzM~ 6p7yx;]6a8=-BG 2022-2023 College Immunization Exemption Application, Nursing Home Flu Policy If you're allergic to something in one of the vaccines, you might be able to get another one of the vaccine brands available, since some of the ingredients are different in each one. An application with a notarized signature of the parent/guardian, or the studentover 18 years of age, must be submitted each school year to the Department of Health. Early Hearing Detection and Intervention Performance, Hospital Reporting Form-Lay Midwife Patient Transfer. Vaccines are the safest way to protect you, your children, and your community from a long list of serious and potentially life-threatening illnesses. 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. (This application works best in Google Chrome.). "There are some people who have received one dose of the vaccine and had a subsequent medical event close in time to the vaccine," said Dr. Schaffner. Pneumococcal Conjugate (PCV13) Exemptions shall be granted only by the Arkansas Department of Health. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Q: What are the immunization requirements for colleges, schools, and daycares? Statistics show that states where exemptions are easy to get have more. <>>> Pleasecomplete your Immunization Exemption Application, print it,sign it, have it notarized, andreturn itto the Arkansas Department of Health Immunization Section. Hepatitis B If aSMART Health Card compatible verifier app is not available, you may present the paper copy of your SMART Health Card. Your medical provider must complete Part 2 of this form. Immunization Requirements for Daycares and Schools. A new Exemption Form Must Be Completed Every School Year. Additional information on SMART Health Cards is available here. The QR code may be scanned into an app on your smartphone and used to verify your COVID-19 vaccination history at places that have a SMART Health Card compatible verifier app, such as airports, business, and large venues. 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. Though some healthcare facilities require healthcare workers to get vaccinations for vaccine-preventable diseases, no state requires vaccines for adults. The Arkansas Department of Health is authorized by Act 999 of 2003 to grant individual exemptions from the immunization requirements. Answer: Yes, please call your local health department to schedule an appointment for vaccinations. Screening Checklist 75.119.198.104 Thiswebsite allows you to submitan application for exemption. 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, Early Hearing Detection and Intervention Performance, Hospital Reporting Form-Lay Midwife Patient Transfer. Still, if you happen to be allergic to any ingredient in one COVID-19 vaccine, experts recommend investigating to see if you can get another vaccine. Regional Health System asks employees requesting a religious exemption from the hospital's COVID-19 vaccine mandate to confirm they will not use. The University of Arkansas for Medical Sciences mandates influenza, MMR, Tdap, Covid-19, Varicella. Office of Performance Management Quality Improvement and Evaluation. Immunization doesnt just protect the person getting the shot; it protects the entire community. 2022-2023 College Immunization Exemption Application, Nursing Home Flu Policy Measles, Mumps, & Rubella <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 11 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endobj Eligible Arkansans can make an appointment with a vaccine provider. Step 1: Identify the correct form for you Right-click this exemption application form (PDF, 1.2 MB) link for hardship exemptions, like homelessness, bankruptcy, eviction, or foreclosure. _{r==gjgLN?NOq*Qr8B?9Rp\>R#*v1u$4*:r'$[NHkF=`u*:N}6bTLzh,b{tM_|+ABb'JqEuTe2N-Bhzc!~gJl$/*^ If you believe there are COVID-19 vaccinations missing from your COVID-19 SMART Health Card, you may reach out to the site where you received the vaccination to have it added to the WebIZ system. If youre still having trouble, If you right-click and are still having trouble, you may need to. 4 0 obj You may already have it. Or E-mail us to request the exemption form. Where can I find theSMART health card FAQs? <>/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>> FLU VIS. For information, inquiries, feedback and comments contact us. . 1 and Hepatitis B (for those exposed to blood and body fluids, vaccinations for all of its employees. What to Know About a Rare Side Effect Tied to J&J COVID-19 Vaccine, Side Effects From the COVID-19 Booster Shot, Interim clinical considerations for use of COVID-19 vaccines currently approved or authorized in the United States, Lipids ((4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate), 2 [(polyethylene glycol)-2000]-N,N-ditetradecylacetamide, 1,2-Distearoyl-sn-glycero-3- phosphocholine, and cholesterol), Lipids (SM-102, 1,2-dimyristoyl-rac-glycero3-methoxypolyethylene glycol-2000 [PEG2000-DMG], cholesterol, and 1,2-distearoyl-snglycero-3-phosphocholine [DSPC]), Recombinant, replication-incompetent adenovirus type 26 expressing the SARS-CoV-2 spike protein. You are responsible for retaining the original letter. It mostly boils down to allergies and allergic reactions to vaccine ingredients said Dr. Schaffner. When approved, exemptions will be effective for the start of the Fall session in 2022 and go through the . Signature of Patient/Parent/Guardian: Please sign here ___________________________Date__________________ RELEASE AND ASSIGNMENT: 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. Click here for a list of clinics. Though the development of a COVID-19 vaccine has followed an accelerated timeline,safety has been the top priority. Meningococcal ACWY The notary page must be printed, signed, notarized and submitted back to ADH before processing can be complete. They can give you allergy testing to see what, exactly, you're allergic to and then recommend the right COVID-19 vaccine for you based on the findings, said Dr. Schaffner. Medical exemptions to the COVID-19 vaccine have been a hot-button topic. Please Click here to download the list of International Travel Physicians who provide immunizations for travelers. 9K3vf%Xn)kQQ/ gVl7uUfAtbA>+,wx&"q]?0@@p !b$z"bb # W0EUf=6js!8y|[W_}?aX 1qE3Vi*{b"-4kC|D!O*8vLq>vr7i>c%>lWg6VE,e02TYZ4 1Y`+?CL4[ m"~daJ`B=7t~r`\BL#\HJYsukuuNx5kjUar>T][!X+UUEm$I9Js Z8nXmnhVFR]GG If you believe there are COVID-19 vaccinations missing from your COVID-19 SMART Health Card, you may reach out to the site where you received the vaccination to have it added to the WebIZ system. Daycare/School Exemption Form or College Exemption Form. HIB Or E-mail us to request the exemption form. Home; Community, Family & Child Health; Immunizations; Immunizations. Answer:There is a medical exemption for nursing home employees for flu vaccination. 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 . All Rights Reserved. 2017 Arkansas Department of Health. NH Immunization Reporting Form for NH's 22-23 To obtain an exemption parents/guardian/student must (1) sign a notarized statement requesting a . For more information, go here. All Arkansans ages 6 monthsor older are now eligible to receive the vaccine. If you do happen to. The application may be completed by parents or guardians of students or by students who are 18 years of age or older. Your IP: PLEASE NOTE: The form requires a signature and seal of a Notary Public. 2017 Arkansas Department of Health. Current Revision Date: 02/2022 Authority or Regulation: 5 U.S.C. Who is eligible to get the vaccine in Arkansas? 3 0 obj Polio Those seeking a medical exemption will need to fill out this form and have it signed by a medical provider certifying that they should not receive the COVID-19 vaccine. 4815 West Markham Street Little Rock, Arkansas 72205-3867 Cell (501) 661-2000 . In Conway, Ark., Matt Troup, CEO of Conway Regional Health System, has granted 45 religious exemptions to employees who refused to get a COVID-19 vaccine. This is for the protection of the exempted child and the protection of others. Locate the exemption PDF document you downloaded to your computer in Step 2. <>/Metadata 513 0 R/ViewerPreferences 514 0 R>> Hepatitis B Arkansas Immunisation Exemption Application. Varicella (Chickenpox), 2023-2024 College Immunization Exemption Application Call 1-800-803-7847 for assistance finding a vaccine in your area or to sign up for an ADH clinic. 2017 Arkansas Department of Health. COVID-19 vaccination a condition of employment for all City employees. A religious exemption from vaccination is allowed for individuals who object to the vaccination because of a sincerely held religious belief . All Rights Reserved. 3 0 obj Click here for a list of clinics. GSA19M-22.pdf [PDF - 689 KB ] PDF versions of forms use Adobe Reader . Dr. Schaffner recommended meeting with an allergist. Q. Tdap (Tetanus, Diptheria, Pertussis) When approved, exemptions will be effective for the start of the Fall session and go through the Summer sessions. 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. j}%}p]\Y p=hWWjh_1Sx,?\Cn*:/*z6ry:R[ztf)c!b!g,#x ~$2Nk2Sl Your patient has requested a medical exemption from this . Thank you for using our online Immunization Exemption Application module. Click to download the Medical Exemption Application Form for nursing home workers. For example, when dozens of employees at Conway Regional Health System in Arkansas sought religious exemptions to a COVID-19 vaccine, citing fetal cells, the CEO sent them a list of common . What conditions could cause someone to be medically exempted from the COVID-19 vaccine? 2 0 obj Pfizer-BioNTech COVID-19 vaccines. 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). Enacted Legislation 2020. Q: When are flu shots needed and where do I get them? % What Are the Differences Between the Pfizer and Moderna COVID-19 Vaccines? The notary page must be printed, signed, notarized and submitted back to ADH before processing can be complete. Health.com uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Answer:Click here to download a copy of the Shot Record Request Form. 2023-2024 Childcare-School Immunization Exemption Application For information, inquiries, feedback and comments contact us. %PDF-1.7 Release and Assignment of the COVID-Then sign in the box at right.19 Immunization Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA). Fax Completed Form to: UAMS Employee Health . As part of the application, the law requires that the parent/guardian or college student complete an educational activity when requesting an exemption. When youre ready to fill out the exemption application: Youll need to have a recent version of Adobe Reader software installed on your computer to open the exemption application. 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. If you do not have access to a printer, you will need to complete the paper form of the application. How do I get information about 2022-2023Mass Flu Clinics? Vaccines are the safest way to protect you, your children, and your community from a long list of serious and potentially life-threatening illnesses. Follow the steps above. Form: GSA19M Request for a Medical Exception to the COVID-19 Vaccination Requirement Form is for GSA Employee use only. Sun Apr 30 2023 06:24:07 GMT-0700 (Pacific Daylight Time) Loading. *Ark. Vaccine clinics and events may also be available in your area through hospitals, health care providers, or your worksite. download the latest version for free right now to be sure, install the most recent version of Adobe Reader software, Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming, California, Colorado, Idaho, Kentucky, Maine, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, Vermont, Washington, Chrome and Firefox users: Choose "Save Link As", Microsoft Edge users: Choose "Save Target As", Safari users: Choose "Download Linked File as". x=ks33"zi'u6q9sf^{~tqK |I$vZ" A $'GYrQ6iQ&EV%Y,)xdx$E.WEm%7xSyIwJ i 9]YI\% T6hyt6wN&w1i,O[r?zKg1Q(KXi[%uH>\a_?>~B44}`H:7?|]rv2O28*X If aSMART Health Card compatible verifier app is not available, you may present the paper copy of your SMART Health Card.

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