COVID-19 Vaccination Medical Exemption Form

Congruent to the Chief Medical Officer of Health of Ontario’s Directive # 6, Paramedic Services must establish, implement and ensure compliance with a COVID-19 vaccination policy requiring its employees, staff, contractors, volunteers and students to provide:

1. proof of full vaccination against COVID-19;
   OR
2. written proof of a medical reason, provided by a physician or registered nurse in the extended class that sets out:
3. a documented medical reason for not being fully vaccinated against COVID-19; AND
4. the effective time-period for the medical reason.

If you have an allergy to the COVID-19 vaccine or a specific medical condition that precludes you from receiving a COVID-19 vaccine, please have your physician complete and sign this form and upload it into CERT’n at your earliest convenience.

Please print the following information:

Paramedic Name:

EHS Number:

Physician Name:

Physician Phone No.:

Physician Address:

The individual listed above should not be immunized for COVID-19 for the following reasons (Please check all that apply):

☐ Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine

☐ Immediate allergic reaction of any severity to a previous dose or known (diagnosed) allergy to a component of the vaccine

Which ingredient caused an allergic reaction?

What was the reaction?

Which brand of the COVID-19 vaccine is contraindicated and why?

How long will the medical contraindication last?

☐ Other Medical Reason – Please provide this information in a separate narrative that describes the other medical reason justifying an exemption in detail.

FOR THE PHYSICIAN

I certify                                                     has the medical condition checked off above

and recommend a medical exemption from COVID-19 vaccination.

Physician Signature:

Date:
(Note: Signature Stamp Not Acceptable)