El Camino College COVID Medical Exemption Vaccine Request- Summer/Fall 2022

This form should only be used by El Camino College students to request a Medical Exemption to the COVID-19 vaccination required by the El Camino College Board of Trustees as stated in Superintendent/President Brenda Thames, Ph.D.'s message.  This decision was based on (a) Medical Exemption due to a Contraindication or Precaution to COVID-19 vaccination recognized by the U.S. Centers for Disease Control and Prevention (CDC) or by the vaccines' manufacturers; (b) Medical Exemption due to COVID-19 diagnosis or treatment with the last 90 days; or (c) Disability.

STOP: Before you begin please have the "Certification from Health Care Provider" form completed and signed by your Health Care Provider.

Student Name*
Part A: Request for Medical Exemption due to Contraindication or Precaution
The Contraindication or Precautions to COVID-19 vaccination recognized by the CDC or by the vaccines' manufacturers apply to me with respect to all available COVID-19 vaccines. For that reason, I am requesting an Exception to the COVID-19 vaccination requirement based on Medical Exemption. My request is supported by the attached certification from my health care Provider. I understand that some local (city/county) public health departments have issued orders specifying that the certification must be signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician.
Part B: Request for Medical Exemption Due to COVID-19 Diagnosis or Treatment
I have been diagnosed with or treated for COVID-19 within the last 90 days. For that reason, I am requesting an Exception to the COVID-19 vaccination requirement based on Medical Exemption. My request is supported by the attached certification from my health care provider. I understand that some local (city/county) public health departments have issued orders specifying that the certification must be signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician.
Part C: Request for Exception Based on Disability
I have a Disability and am requesting an Exception to the COVID-19 vaccination requirement as a Disability accommodation. My request is supported by the attached certification from my health care provider. I understand that some local (city/county) public health departments have issued orders specifying that the certification must be signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician.
While my request is pending, I understand that I must comply with the Non- Pharmaceutical Interventions (e.g., face coverings, regular asymptomatic testing) for unvaccinated or not fully vaccinated individuals as a condition of my Physical Presence at any El Camino College Location/Facility or Program. These required Non- Pharmaceutical Interventions are defined by my Location’s public health, environmental health and safety, occupational health, or infection prevention authorities, including the Location Vaccine Authority. I also understand that I must comply with any additional Non-Pharmaceutical Interventions applicable to my circumstances or position, as required by my Location. If my request is granted, I understand that I will be required to comply with Non-Pharmaceutical Interventions specified by my Location as a condition of my Physical Presence at any El Camino College Location/Facility or Program.*
Any statements found to be given in false testimony in either written or verbal form may be pursued via the Student Conduct process.
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