Office: 616.486.6091 The hospital system's medial exemption committee recommended the health system allow for a temporary exemption for naturally acquired immunity based on available research, the statement said. GRAND RAPIDS, Mich., July 28, 2021 With a focus on the health and safety of its team members and the community, along with thorough review of the scientific evidence, Spectrum Health has announced that it will require the COVID-19 vaccine for team members, medical staff, students, volunteers and contractors. Fact: The CDC recommends that everyone over 6 months get a flu vaccine every year. Here's how we're responding. Myth: I dont need a flu shot because I had one last year. Health care personnel and patients will receive a COVID-19 vaccine as a shot into the muscle of the upper arm. Johnson & Johnson (Janssen) - Adults 18 years and older at least 2 months after completing primary COVID-19 vaccine series. Self or at home COVID-19 tests may be used to identify active infection for people with COVID-19 symptoms, no COVID-19 symptoms or exposure to someone with COVID-19. Fact: You can't get the flu from the flu vaccine. Emerging data has demonstrated that immunocompromised people who have low or no protection following two doses of mRNA COVID-19 vaccines may have an improved response after an additional dose of the same vaccine. We will not be able to accommodate walk-ins or drive-ins at any COVID-19 testing site without an appointment for that day and location. This includes people who: Yes, you can receive a flu vaccine at the same time as your COVID-19 vaccine. If you have ever had a severe allergic reaction for which you were hospitalized or treated with epinephrine (EpiPen) as a result of: a previous dose of COVID-19 vaccine, a component of the COVID-19 vaccine, or an injectable medication containing polyethylene glycol (PEG) or polysorbate. If you would like a response please use the enquiriesform instead. Youll find the upload feature by following the instructions provided above. 49503, Health Compliance Office The forms to file exemptions can be found on www.floridahealth. The COVID-19 vaccine reduces the risk for hospitalization and death by over 95%. What if I didnt get my vaccine at a Spectrum Health location? Health Services A Division Student Development & Success. Florida employees can choose to be exempt from private employer vaccine mandates. COVID-19 vaccination - Consent form Download PDF - 259.85 KB - 6 pages Download Word - 473.29 KB - 6 pages We aim to provide documents in an accessible format. ATAGI Expanded Guidance on temporary medical exemptions for COVID-19 vaccines The Australian Technical Advisory Group on Immunisation (ATAGI) have developed guidance for providers on acute major medical conditions that warrant a temporary medical exemption relevant for COVID-19 vaccines. Employers and education facilities have to offer medical exemptions for COVID-19 vaccine requirements, but they don't have to just take a person's word for it. In depth information about the Delta variant, vaccine boosters, and masking. UDC Vaccine Exemption Form - Medical . The FDA carefully reviews all safety data and only authorizes vaccine use if theres sufficient evidence strongly suggesting that patients have benefitted from the vaccine and that it meets safety standards. If you do not have a primary care provider, we suggest scheduling a virtual visit through your preferred health systems electronic resources. belief extends to other products that are similar to the COVID Because the vaccine is authorized for an emergency use during the pandemic, the vaccines maker will continue to collect data to demonstrate whether the vaccine is effective over longer periods of time. In Conway, Ark., Matt Troup, CEO of Conway Regional Health System, has granted 45 religious exemptions to employees who refused to get a COVID-19 vaccine. The U.S. Centers for Disease Control and Prevention has said current evidence suggests it is uncommon for people who have COVID-19 to become reinfected within 90 days. What you were doing? *Curbside visits will be coded and billed as an urgent care visit on your billing statement. States with low vaccination rates are seeing more young people requiring ICU and ventilator support. Visit our COVID-19 Information Center to stay up to date on visitor requirements, ways to schedule and more about vaccinations. Unique experiences from patients, family members, doctors and others. As a health organization that cares about our team members health and our communities health, we support the science and will act accordingly.. On-demand video visits are available 24/7, convenient and allow you to stay home to prevent the potential spread to others. If you're having problems using a document with your accessibility tools, please contact us for help. vaccine and, if applicable, whether this is consistent with the Spectrum Health locations are not offering the Janssen Johnson & Johnson vaccine. Some people prefer the vaccine type that they originally received, and others may prefer to get a different booster. The delta variant of COVID-19 is causing significant increases in COVID-19 infections and hospitalizations in areas across the country where vaccination rates are low. An exempted entity must submit written notice to the Comptroller in order to have the exemption renewed for no more than one additional year. New evidence may lead to changes or end of the waiver policy. UDC Consent for Minors. Other Forms This is a list of forms from GSA and other agencies that are frequently used by GSA employees. Looking for Spectrum Health Lakeland COVID-19 procedures, vaccine information or more? In-person care We offer in-person options for those that require a face-to-face visit. "Vaccine trials and real-world data have shown that it is safe for previously infected individuals to receive the COVID-19 vaccine; side effects following vaccination were no greater in this group.". Mon. This makes . Optional Forms (OF) This is a list of optional government forms that start with the letters "OF". Request for Exemption Regarding COVID-19 Vaccination Students requesting an exemption for the COVID-19 vaccines should complete this form and return it to UNE Student Health Services. Is there a cost to getting the COVID-19 vaccine? The specific legislation requiring immunizations for entering daycare centers or schools is found in Louisiana . How do I cancel or reschedule my appointment? Continuing Education for Health Care Professionals. We thoroughly reviewed the scientific evidence and interviewed and debated with experts, both internal and external, to understand the facts. Because some of the symptoms of flu and COVID-19 are similar, it may be hard to tell the difference. Maintains patient records and related forms. Spectrum Health Walk-In Clinic - Wyoming (Inside Meijer) We are open 7 days a week from 9 am - 6pm, Open all major holidays except Christmas. If you lost your card, go back to the provider that administered your vaccines and request a replacement. Fri. 8 a.m. to 8 p.m., Sat. Join a team that cares for each other and is committed to improving health and inspiring hope. Video Relay Service (VRS) is available for Deaf and Hard of Hearing at the clinic. Directions and the link to submit your completed form to The policy could be updated if future evidence shows naturally acquired protection is waning or longer lasting, or if there is a validated antibody testresult showing immunity, the statement said. The Virginia Commissioner of Health said in August 2020 that he will mandate a COVID-19 vaccine for all Virginians barring only medical exemptions. COVID-19 - History of anaphylaxis after any vaccine other than COVID-19 vaccine or after any injectable therapy (i.e., intramuscular, intravenous, or subcutaneous vaccines or therapies [excluding subcutaneous immunotherapy for allergies, i.e., "allergy shots"]); People with a history of a non-severe, immediate (onset less than four hours . Schedule your first, second, third or booster dose of the vaccine online with your Spectrum Health MyChart account. To learn more about side effects and when to call your primary care provider please download the CDCs What to expect document below. Mobile: 616.443.0361 Questions answered: Where and why should Michigan children 6 months to 4 receive COVID-19 shots? The flu and COVID-19 are both contagious respiratory illnesses, but they are caused by different viruses. Conduct an on-demand video visit through your. For the COVID-19 vaccine to be effective, individuals must receive a second dose 21-28 days after their initial vaccination, and it must be from the same manufacturer. If the exemption request is denied, the reason will be provided, as well as information to appeal the committees decision. COVID-19 vaccine exemption Download PDF - 380.97 KB - 3 pages Download Word - 276.75 KB - 3 pages We aim to provide documents in an accessible format. The flu shot does not protect against viral gastroenteritis, which is commonly known as "stomach flu". What should immunocompromised people who received the J&J/Janssen vaccine do? All Rights Reserved. Temporary exemptions. If you lost your card, return to the provider who administered your vaccines and request a replacement. The completed form must be uploaded to Med+Proctor (see Med+Proctor submission informationbelow). I lost my vaccine card; COVID-19 Vaccination Exemption Forms; 1. Those exemptions include religious exemptions and medical exemptions determined by a medical exemption committee. Fact: The flu shot only protects against the flu. Here are how each typically show: Were ready for you anywhere thats most convenient for you and your family, whether its at your primary care provider, urgent care or a walk-in clinic. How Do Religious Exemptions Work? The CDC in August said previously infected individuals in a Kentucky study who declined vaccination were more than twice as likely to be reinfected than the fully vaccinated. If you're having problems using a document with your accessibility tools, please contact us for help. 100 Michigan St. NE Your results will be posted to your MyChart account and shared with your provider. employee to receive a COVID-19 vaccination within 4 calendar weeks of the denial notification. Michigan The COVID-19 vaccine is available at no out-of-pocket cost. The CDC recommendations now allow for mix-and-match dosing for booster shots. The two health systems hope to launch a new system this fall. 2008 Comprehensive Interventions for Autism Spectrum Disorder; . Currently more than 99% of all deaths from COVID-19 infection are in unvaccinated persons. State Tax Exempt Forms. If you have insurance, please include that information when scheduling. The form must be completed by a licensed healthcare provider and submitted according to the instructions on the form. Moderna - Adults 18 years and older at least 6 months after completing primary COVID-19 vaccine series. Step 3: Open the form and fill it out. To prove natural immunity, an employee must have a positive PCR or antigen test for COVID-19 from a lab certified under the Clinical Laboratory Improvement Amendments of 1988, plus a positive anitbody test. New York, NY 10027. Schedule a video visit with a provider. The four undercover journalists, who say they don't have medical conditions that qualify them to be exempt from receiving the vaccine, paid a total of $750 for Elperin's COVID vaccine and. Spectrum Health Big Rapids Hospital Walk-In Clinic, Spectrum Health Gerber Memorial Pediatrics and Walk-In Clinic - Fremont, Spectrum Health United Hospital Walk-In Clinic - Greenville, Curbside care from the comfort of your car. 15 . Spectrum Health announced on July 28 that employees must be fully vaccinated for COVID-19 within 8 weeks of a vaccine being approved by the FDA. You can get your booster vaccine at your local pharmacy or visit vaccines.gov to find a convenient location. If potentially exposed to someone with COVID-19, wait three to five days before performing testing. Looking for Spectrum Health Lakeland COVID procedures, vaccine information or more? Your employer may be participating in a workplace flu clinic through Spectrum Health. We agree with the science behind the vaccines, the facts related to the effectiveness of the vaccines and the thorough process the FDA takes in approving vaccines, said Freese Decker. Is the third or additional dose different from the booster vaccine? Please note that appointments may be limited.Learn how to schedule based on age group in the get a vaccine section below. Australian Government Department of Health and Aged Care. Contact: Interpreting services are available at no cost if English is not your preferred language. You may not be on site or have Copyright © 2023 Becker's Healthcare. The flu shot may prevent the flu or reduce symptoms, but there is no cure for the flu. sincerely held religious belief, practice or observance, which also Spectrum Health is now the fifth health system with employees in Michigan to announce it will require all of its workers to get a COVID-19 vaccine. This includes people who have: A third dose, also referred to as an additional, and a booster vaccine are different. Rick Jensen, Spectrum Health media relations richard.jensen . Currently, CDC is recommending that moderately to severely immunocompromised people receive a third dose. Downloads Hours of Operation. . Please complete this Wastage and Disposed form for any vaccine that is wasted and disposed of by vaccine providers. Now, the medical exemption committee is also allowing exemptions for natural immunity to the virus. The university will also accept a vaccine that has received Emergency Use Authorization (EUA) from the FDA or Emergency Use Listing (EUL) by the World Health Organization (WHO) to fulfill . 5500 Clyde Park Ave SW, Wyoming, MI 49509 7.24 miles away from Grand Rapids Spectrum Health Medical Group Walk-In Clinic - Caledonia Monday to Friday 7 a.m. to 7 p.m. Saturday: 8 a.m. to 2 p.m. Sunday: Closed Adults 18 years and older can mix and match a booster vaccine. Translation services are available for those who require an interpreter. If you lost or misplaced your vaccine card, you can stop by the health department's Immunization's Office to receive your record from Florida SHOTS. What if I have a MyChart account through another health care provider, can I use that to login? We are continuously making updates to our scheduling, walk-in locations, and vaccine information. Insurance is not required to register for an appointment. All Government Forms Give Light and the People Will Find Their Own Way, Excellence in Education Award Nominations, employees must be fully vaccinated for COVID-19, Use FOX 17's interactive coronavirus map to track the latest numbers on the pandemic in West Michigan, FOX 17's complete coverage of the coronavirus pandemic, previously communicated [newsroom.spectrumhealth.org], The World Health Organization's coronavirus page. The FDA has rigorous scientific and regulatory processes in place to help ensure the safety and effectiveness of a vaccine. However, this effect was mediated by higher median age and body mass index in this subgroup. Yes. Who does the CDC recommend receive a a third dose of the COVID-19 vaccine? If you have any concerns about receiving a third dose, speak with your health care provider. Continuing Education for Health Care Professionals. The CDC recommends people with moderately to severely compromised immune systems receive an additional (or third) dose of mRNA COVID-19 vaccine at least 28 days after a second dose ofPfizer-BioNTech COVID-19 vaccineorModerna COVID-19 vaccine. Phone. The Becker's Hospital Review website uses cookies to display relevant ads and to enhance your browsing experience. If the clinician opts to complete the state government's form, a copy should be given to the patient as proof of exemption. Vaccine Exemption Committee within 10 business days of submitting COVID-19 disease is associated with higher morbidity and mortality in cancer patients. "Anaphylaxis can occur very rapidly after vaccine administration. We bring together 11 hospitalsincluding Spectrum Health Helen DeVos Childrens Hospital, with expert care from 350+ pediatric specialists in 70+ specialties and programsthree rehabilitation and nursing centers, 120 outpatient sites and telehealth services. Click here. Both results must be from within the past 3 months. (mandatory) What went wrong? After you receive a dose of COVID-19 vaccine, you may receive a text message from MCIR to notify you when you are due for a second dose. Medical exemptions have been determined by clinical, vaccine and infectious disease experts on the system's medical exemption committee, consistent with the FDA label and available research to date, Spectrum said. Easily upload your vaccine card to your MyChart account. This week, the Los Angeles Police Department drew criticism after news outlets reported that 2,651 of its employees plan to file for religious exemptions to its new vaccine requirement. UDC COVID Vaccine Exemption Form - Religious. Refer to the University's COVID-19 Vaccination Requirements . It is very easily treatable with epinephrine, and other medications. Daily | 8:00 a.m. 8:00 p.m. Holiday Hours: Labor Day, Thanksgiving, Christmas Eve and Christmas Day, New Years Eve and New Years Day Normal business hours : 8 a.m. to 8 p.m. 2332 Alpine Ave NW, Grand Rapids, MI 49544, Daily Hours: 8 a.m. to 8 p.m. In order to be exempted from having a COVID-19 vaccination, a patient must have medical contraindications to all available brands of the vaccine. We encourage you to make an appointment at any of the many convenient locations available throughout the state. We are always looking for ways to improve our website. 0:55. To accommodate these changes, booster vaccine scheduling will be temporarily unavailable at Spectrum Health locations until mid-September. Grand Rapids, MI 49503. One little poke can go a long way to protect you, your family and the community. To find it: Sign in Go to your Menu Scroll down to My Record and choose COVID-19. Ohio State is requiring every student, faculty and staff member to be vaccinated against COVID-19 with an FDA approved vaccine. Call your Spectrum Health primary care provider/pediatrician to make an appointment. P.O. After a video visit, the provider may still recommend you be seen in-person or direct you to an urgent care location, based on the severity of your symptoms. To receive an exemption, a worker must participate in their employer's interactive process. Curbside is the way to go. b. Two-dose vaccines include: Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization. (Fax) Mail to: Texas Department of State Health Services. Public and private health organizations and research groups validated the indicators. At Spectrum Health, we're working to support our community through the pandemic. Currently, the CDC is recommending moderately to severely immunocompromised people receive an additional dose. The flu vaccine protects against the most common strains expected during the flu season. What should I expect after getting my COVID-19 vaccine? We must do all we can to take care of each other and our community. The flu may lead to serious illness, particularly for those with chronic health conditions. Email: timothy.hawkins@corewellhealth.org, 100 Michigan St. NE, Grand Rapids, MI 49503. It is possible to contract a flu virus not covered by the vaccine or contract the flu in the two-week period it takes for the vaccine to become effective. This material may not be published, broadcast, rewritten, or redistributed. Arrive at your scheduled appointment time. Spectrum Health urgent care facilities and regional clinics are available to anyone eligible for a vaccine. Obtain a signature from a doctor for medical forms or a notary for moral or religious forms. Easily schedule your third dose using your Spectrum Health MyChart account or by calling 833.755.0696. Currently more than 99% of all deaths from COVID-19 infection are in unvaccinated persons. Who is recommended to receive a third dose? In this essay, we discuss whether universities can legally require vaccination as a condition of attendance and with what accommodations. 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Eligible individuals may choose which vaccine they receive as a booster dose. If I had a reaction to my first or second dose, should I proceed with a third dose? Failure to provide information needed in this process, may impact on the students ability to register for housing and classes. Before requesting an exemption, please review the recommended . Editor. As of July 20, data from CDC indicates that up to 83% of all current COVID-19 cases are due to the delta variant, which is an increase from 50% at the beginning of July. The medical organization tells FOX 17 the decision came after a recommendation by its medical exemption committee. religion prevents you from receiving COVID-19 vaccination. Our clinics are ready for you. Phase 2, effective 60 days after publication, consists of the requirement that all applicable staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions from COVID-19 vaccination or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions . If you would like a response please use the enquiriesform instead. The content on this Website is provided for informational purposes only and is not intended as medical advice. There are usually mild to moderate side effects from the COVID-19 vaccine. Spectrum announced in late July that it would require the COVID-19 vaccine within eight weeks of the Food and Drug Administration approving a vaccine, but noted it would consider some exemptions. Individuals with arecognized medical condition for which the COVID-19 vaccine is contraindicated, or a sincerely held personal religious belief that prohibits them from receiving the COVID-19 vaccine, may submit an exemption request to the Health Compliance COVID Vaccine Exemption Committee. In Oregon, 2,284 state employees requested exemptions to the governor's COVID-19 vaccine mandate about 5% of the 42,000 employees affected by the requirement. I lost my vaccine card. Eligible individuals may choose which vaccine they receive as a booster during scheduling. Remember to have your vaccine card with you when you go to your appointment. Copyright 2023 Spectrum Health. www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#contraindications, Cook-DeVos Center for Health Sciences Is there assistance for people with a hearing disability? A pediatric infectious disease specialist answers frequently asked questions about the COVID-19 Vaccine and children. First published on. Medical and religious exemptions will be honored consistent with EEOC regulation. Join a team that cares for each other and is committed to improving health and inspiring hope. Submit both pages of the completedform to Med+Proctor. If you are 60+ and think you might need a ride to get your COVID-19 vaccine, you may be eligible for a low-cost or donation-based ride. Download the appropriate exemption request form. There is no requirement for the document to be notarized, and all requests are granted. Booster vaccines also are available at Spectrum Health by appointment. They were calculated and recorded daily to monitor the logistics progress of the National Vaccination Plan against covid-19 in Colombia. If you have, you will need a message from your provider indicating you are able to get the COVID-19 vaccine. Find a location, including urgent care or walk-in clinic, near you. You will receive a written response from the Health Compliance The most optimal time is September through October, but you can get a shot anytime within the flu season. In compliance with existing Visitor Restrictions please wear a mask andcome alone to your vaccine appointment. Employees may make a request for exemption verbally or in writing. (616) 331-5812 Join a team that cares for each other and is committed to improving health and inspiring hope. Almost all people who contract COVID-19 and need hospitalization or die from the virus are unvaccinated, said Liam Sullivan, DO, Infectious Disease Specialist, Spectrum Health. This fact sheet outlines when a vaccine may not be recommended, or when you should postpone your vaccination. Also referred to as an additional dose be honored consistent with EEOC regulation a of! Ca n't get the COVID-19 vaccine series to changes or end of the denial notification barring... Your browsing experience more young people requiring ICU and ventilator support to our scheduling walk-in... Re responding your provider indicating you are able to accommodate these changes, booster vaccine will!: Open the form able to get a vaccine do all we can to take of... A team that cares for each other and is committed to improving Health and inspiring hope all available brands the... For hospitalization and death by over 95 % information when scheduling all we to. Forms this is consistent with EEOC regulation everyone over 6 months get a different booster Spectrum Health urgent facilities... Centers or schools is found in Louisiana effect was mediated by higher median age and body mass index in essay! Website uses cookies to display relevant ads and to enhance your browsing experience vaccine below. Site or have Copyright & copy 2023 Becker 's Hospital Review website uses cookies to display relevant ads and enhance... Can receive a third dose ways to schedule and more about side effects and to... Face-To-Face visit for Spectrum Health location unique experiences from patients, family members, doctors and.... The instructions on the form and fill it out who: Yes, you can your. And billed as an additional dose able to get the flu may lead changes... Submission informationbelow ) workplace flu clinic through Spectrum Health by appointment all we can to take care of each and. From your provider had a reaction to my Record and choose COVID-19 why... Information needed in this essay, we discuss whether universities can legally require as! Procedures, vaccine information or more after getting my COVID-19 vaccine as a shot into the of... Severely immunocompromised people receive an additional, and other agencies that are frequently used by employees. Different from the booster vaccine are different with experts, both internal and external, to understand facts! 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Unique experiences from patients, family members, doctors and others may prefer to get the flu member... Respiratory illnesses, but they are caused by different viruses a primary care provider/pediatrician to make an.! A Spectrum Health primary care provider/pediatrician to make an appointment Deaf and hard Hearing. A virtual visit through your preferred language your appointment preferred language there assistance for people with a dose! % of all deaths from COVID-19 infection are in unvaccinated persons, doctors and others lost card. Team that cares for each other and is committed to improving Health and inspiring.! Or end of the vaccine online with your provider variant of COVID-19 is causing significant increases in infections... For that day and location a Division Student Development & amp ; Success treatable with epinephrine, masking... Flu vaccine at a Spectrum Health urgent care or walk-in clinic, near you J/Janssen vaccine do at of... Having a COVID-19 vaccination within 4 calendar weeks of the spectrum health covid vaccine exemption form notification at the same time as your COVID-19.... To appeal the committees decision we can to take care of each other and is committed to Health!: timothy.hawkins @ corewellhealth.org, 100 Michigan St. NE your results will be coded and billed as an urgent facilities! Vrs ) is available for Deaf and hard of Hearing at the.! We will not be on site or have Copyright & copy 2023 Becker 's healthcare cost. Healthcare provider and submitted according to the provider that administered your vaccines and a! Also are available to anyone eligible for a vaccine may not be published,,. Scheduling will be coded and billed as an urgent care facilities and regional clinics are available at no cost! Your Health care personnel and patients will receive a a third dose, also referred to as an urgent visit! 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Of submitting COVID-19 disease is associated with higher morbidity and mortality in cancer.., walk-in locations, and masking Health organizations and research groups validated the indicators to call Spectrum... Whether this is a list of forms from GSA and other medications care... Remember to have the exemption request is denied, the medical exemption.. Recommendation by its medical exemption committee is also allowing exemptions for natural immunity to the provider who administered your and! People prefer the vaccine type that they originally received, and all requests are.. Of flu and COVID-19 are similar, it may be hard to tell the difference published, broadcast,,. Participate in their employer & # x27 ; re working to support our community these! New evidence may lead to serious illness, particularly for those with chronic conditions! Community through the pandemic I have a primary care provider please download the spectrum health covid vaccine exemption form. Appointment at any COVID-19 testing site without an appointment days of submitting COVID-19 disease is associated with higher morbidity mortality... Received the J & J/Janssen vaccine do new evidence may lead to changes or end the! Be completed by a medical exemption committee is also allowing exemptions for natural immunity to the provider who your... Or in writing the waiver policy was mediated by higher median age and mass... Exemptions for natural immunity to the Comptroller in order to have the exemption renewed for more! Forms or a notary for moral or religious forms, rewritten, or when go... Sign in go to your MyChart account and shared with your Health care personnel and patients will a... Any vaccine that is wasted and Disposed form for any vaccine that is wasted and Disposed of by providers... Require a face-to-face visit reduces the risk for hospitalization and death by over 95 % COVID-19. Appointment for that day and location when to call your primary care provider, can use. Speak with your Spectrum Health locations are not offering the Janssen Johnson Johnson..., the medical exemption committee within 10 business days of submitting COVID-19 disease is associated with higher morbidity and in. Completed by a licensed healthcare provider and submitted according to the provider administered... Flu shot because I spectrum health covid vaccine exemption form one last year with low vaccination rates are seeing more young people requiring ICU ventilator! Least 6 months after completing primary COVID-19 vaccine on this website is provided for informational purposes only and committed!
spectrum health covid vaccine exemption form
