Medical Exemption Denials

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As part of our legislative advocacy efforts, Health Action MA is collecting medical exemption denial testimonies for children/teens, by medical professionals in Massachusetts.

Whether for a vaccine injury, family history or condition, please complete the form below.

Disclaimer:

Information submitted in this form will not be shared publicly or with any third parties.

Thank you

Questions? Email hello@healthactionma.org

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Email *

First Name *

Last name *

Town *

Zip Code *

Phone Number

Who is filling out this form *

I am the child/teen who was denied an exemption

I am the parent/guardian of the child/teen denied an exemption

Other:

Reason for medical exemption *

Child/teen suffered an adverse event to a vaccine

Sibling suffered an adverse event to a vaccine

Immediate family medical history

Child/teen has a medical condition

Other

If 'other' please detail

Was the exemption needed for school or services (such as Early Intervention). *

Yes

Was the medical provider located in Massachusetts *

Yes

If the medical exemption request was due to a vaccine adverse event, was the injury documented? *

YES

UNSURE

NOT APPLICABLE

If the medical exemption request was due to a vaccine adverse event, was it
*

COVID-19

Flu shot

Vaccinations required per the school schedule.

NOT APPLICABLE

Reasons given for exemption denial *

Condition/history or injury is not a CDC contraindication

Practice policy does not allow for medical exemptions to be written

Provider refused and recommends continuing vaccinations

Provider recommends no further vaccinations but will not write an exemption

Other

If 'other' please detail

Please provide a brief description of the exemption denial *

Future Communications: Do you consent to future communications from Health Action MA regarding legislative action/updates for medical exemption denials. *

YES - I consent to receiving communications from Health Action MA for medical exemption denials legislative updates

NO - I do not consent to communications from Health Action MA for medical exemption denials legislative updates

I would like to testify (written and/or verbally) before the legislature regarding my exemption denial. Please note: this will be public record. *

Yes

A copy of your responses will be emailed to the address you provided.

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