Get For Use Of This Form, See Requiring Document

This guide provides clear instructions on how to correctly fill out the For Use Of This Form, See Requiring Document. Following these steps will help ensure that all necessary information is accurately submitted for the exemption request.

Follow the steps to complete the exemption request form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. In the section labeled 'Requiring Document,' enter the title and number of the document that requires the completion of this form, followed by the issuance date.
3. For the 'Local Form Title,' you may enter 'Influenza Vaccination Medical Exemption Request' if applicable.
4. Complete the confidentiality statement by ensuring you understand how to handle the personal and sensitive information on this document.
5. Fill in the date, and add your printed name as the applicant.
6. In the section for immunizations, tick the box next to each immunization from which you are seeking exemption, as listed.
7. Specify the medical reason for your exemption by checking the relevant reason(s) provided.
8. Provide any reviewer remarks, if applicable, indicating if your exemption has been exempted or is pending.
9. Enter the reviewer's name, signature, and the date of review.
10. Complete the patient’s identification section by filling in the required details including name, Social Security Number (SSN), sex, date of birth, rank/grade, and any other relevant information.
11. Detail the hospital or medical facility where records are maintained, along with your status and department/service.
12. Provide the sponsor’s name, SSN, and relationship to the sponsor.
13. Once all fields are accurately filled out, save your changes, and you can choose to download, print, or share the completed form as needed.

Take the next step toward managing your exemption request by completing the required documents online.