Immunization personal exemption record (GRS-569)

Description

This is a statewide form provided by the Department of Health to all local health departments. It is used by parents to claim a personal exemption based on a personal belief opposed to immunization in accordance with Utah Code 53G-9-304(2019). This form must be completed annually to receive continued recognition of the personal exemption. It includes a statement claiming exemption from immunization, parent or guardian's name and signature, address, date, name of child/student exempted, date, school or child care facility's name, witness's signature, title, and date.

Retention and Disposition

Retain until 21 years after date of birth, and then destroy records.

Appraisal Value

These records have administrative value(s).

Appraisal