New York University
Exemption from Immunization Requirements
Waiver Form
I am seeking an exemption from New York University’s immunization requirements for the
following vaccines:
□ Measles, Mumps, Rubella (MMR)
□ Meningococcal Meningitis
My exemption is based on:
□ a sincere and genuine religious belief which is contrary to the practice of immunization, and I
have completed, signed, and submitted NYU’s Request for Religious Exemption to Immunization
Form.
□ a valid determination that such vaccination is detrimental to my health or otherwise
medically contraindicated and I have submitted NYU’s Request for Medical Exemption to
Immunization Form for each vaccine from which I am seeking an exemption, completed and
signed by my healthcare provider.
If the exemption is granted, I agree to release and hold harmless New York University in the
event of any illness or injury resulting from my decision to remain unvaccinated. I understand and
accept the risks posed by remaining unvaccinated in a densely populated higher education
community. I acknowledge and agree that I may be required to comply with additional safety
protocols, including ongoing testing requirements, and/or may be temporarily excluded from
certain facilities or activities to protect my health and safety and that of the community in
accordance with public health guidelines and University policies. I also acknowledge and agree
that in such case I will not be entitled to any reduction or refund of tuition or fees and will be
solely responsible for any resulting expenses incurred or other consequences such as missed
classes.
Student's Name and Date of Birth: _______________________________________
Please sign below to indicate your agreement and to verify that all materials you have submitted in
connection with your exemption are truthful and accurate:
Signature of Student (if 18 or over) Date
Signature of Parent or Guardian (if under 18) Date
MMR (Measles, Mumps, Rubella) Vaccine Medical Exemption Certification
Student's Name: _____________________________________________________
Student's Date of Birth: ________________________________________________
Instructions
This form must be completed and signed by a physician (MD, DO), nurse practitioner (NP, FNP), or
physician assistant (PA, PA-C) with a valid and active license in the United States. International students
may have the form completed and signed by a physician licensed in their country of residence. Family
members and personal acquaitances of the student are not allowed certify on behalf of the student. The
clincian must certify that the vaccine(s) identified below is medically contraindicated or has a specific
detrimental impact to the student’ s health.
Medical exemptions will be granted on a temporary basis when the condition supporting an exemption is
expected to resolve or expire. The certifying medical provider must set an expected end date to temporary
exemptions or the exemption will expire at the end of the current semester. All exemption requests are
subject to review by physicians at the NYU Student Health Center who may further consult with the Centers
for Disease Control and Prevention and/or request additional information from the student’ s provider.
Please select the reason why the student is unable to safely receive any currently available
Measles, Mumps, Rubella vaccines from GlaxoSmithKline or Merck.
[ ] MMR vaccine is contraindicated or not recommended based on CDC guidance
Specify Reason: __________________________________________________________
[Link]
[ ] Student has a medical condition or situation that is listed by CDC as a precaution and guidance
supports waiting or not vaccinating.
Specify Reason: __________________________________________________________
Length of exemption and/or date of expiration: __________________________________
I attest that I am 1) a medical provider licensed in the United States as an M.D., D.O., N.P., or
P.A. or 2) a non-U.S. licensed physician with a degree equivalent ______
to an M.D. and that my
scope of practice includes making decisions about and ordering vaccinations for my patients.
I further attest that I am not a family member or personal acquaintance of the individual
identified on this form. They are my patient and I have provided documented medical care to
them in a professional setting.
I certify that the vaccine identified above is medically contraindicated or otherwise severely
detrimental to the student’ s health for the reasons identified below. I certify that this decision
was made in consultation with the student and by applying the best available medical evidence
to date. I understand and accept the risks posed to the student by remaining unvaccinated in
a densely populated higher education community.
Name and Professional Credentials: ____________________________________________
Signature: _________________________________________________________________
Date: ________________________________________________
Phone Number: ________________________________________
License Number and Jurisdiction: __________________________
Meningococcal ACWY Vaccine Medical Exemption Certification
Student's Name: _____________________________________________________
Student's Date of Birth: ________________________________________________
Instructions
This form must be completed and signed by a physician (MD, DO), nurse practitioner (NP, FNP), or
physician assistant (PA, PA-C) with a valid and active license in the United States. International students
may have the form completed and signed by a physician licensed in their country of residence. Family
members and personal acquaitances of the student are not allowed certify on behalf of the student. The
clincian must certify that the vaccine(s) identified below is medically contraindicated or has a specific
detrimental impact to the student’ s health.
Medical exemptions will be granted on a temporary basis when the condition supporting an exemption is
expected to resolve or expire. The certifying medical provider must set an expected end date to temporary
exemptions or the exemption will expire at the end of the current semester. All exemption requests are
subject to review by physicians at the NYU Student Health Center who may further consult with the Centers
for Disease Control and Prevention and/or request additional information from the student’ s provider.
Please select the reason why the student is unable to safely receive any currently available Meningococcal
ACWY vaccines from GlaxoSmithKline, Pfizer, or Sanofi.
[ ] Meningococcal vaccine is contraindicated or not recommended based on CDC guidance
[Link]
Specify Reason: __________________________________________________________
[ ] Student has a medical condition or situation that is listed by CDC as a precaution and guidance
supports waiting or not vaccinating.
Specify Reason: __________________________________________________________
Length of exemption and/or date of expiration: __________________________________
I attest that I am 1) a medical provider licensed in the United States as an M.D., D.O., N.P., or
P.A. or 2) a non-U.S. licensed physician with a degree equivalent ______
to an M.D. and that my
scope of practice includes making decisions about and ordering vaccinations for my patients.
I further attest that I am not a family member or personal acquaintance of the individual
identified on this form. They are my patient and I have provided documented medical care to
them in a professional setting.
I certify that the vaccine identified above is medically contraindicated or otherwise severely
detrimental to the student’ s health for the reasons identified below. I certify that this decision
was made in consultation with the student and by applying the best available medical evidence
to date. I understand and accept the risks posed to the student by remaining unvaccinated in
a densely populated higher education community.
Name and Professional Credentials: ____________________________________________
Signature: _________________________________________________________________
Date: ________________________________________________
Phone Number: ________________________________________
License Number and Jurisdiction: __________________________
