AGENCY: Southwest Utah Public Health Department (Utah)

SERIES: 16846
TITLE: Immunization personal exemption record
DATES: undated
ARRANGEMENT:

DESCRIPTION: This is a statewide form provided by the State Health Department 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 UCA_53A-11-302.5 (1995). 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

Retain for 21 year(s) after date of birth

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series is authorized by Archives general schedule Immunization personal exemption record, GRS-569

AUTHORIZED: 10/18/1995

FORMAT MANAGEMENT

Paper: Retain in Office until student reaches age of 21 and then destroy.

APPRAISAL

PRIMARY DESIGNATION

Private

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