the case of any child whose parent or guardian objects in
writing to such immunization on religious grounds[.] if the
parent or guardian provides to the school a signed document, on
a form prescribed by the department, stating that the parent or
guardian is declining one or more immunizations on behalf of the
child. The document must include:
(i) the reason for declining immunization;
(ii) the specific immunizations for which an exemption is
being required; and
(iii) a signature from a health care practitioner verifying:
(A) the health care practitioner has reviewed with the
parent or guardian information regarding the benefits and risks
associated with immunization, including the risks associated
with not immunizing a child, consistent with information
published by the Centers for Disease Control and Prevention;
(B) the health care practitioner has reviewed with the
parent or guardian information regarding the possibility that
the child may be excluded from school in the event of an
outbreak until the child is treated or until the exclusionary
period ends; and
(C) the date on which the health care practitioner provided
the information under clauses (A) and (B).
(2) The form prescribed by the department under paragraph
(1) shall be accepted in lieu of a certificate of immunization
and shall be provided by the parent or guardian to the school at
the beginning of each school year.
(e) If, upon review, the requirements of this section are
not met, the school administrator or the school administrator's
designee may exclude the child from school.
(f) As used in this section, the term "health care
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