COVID-19 Certificate of Exemption

COVID-19 Request for Exemption

MSU Denver requires all students, faculty and staff to be vaccinated for COVID-19, including having received a booster shot (when eligible to do so). All students, regardless of mode of instruction, must comply with this requirement by the semester deadline (see dates on Health Center At Auraria).

The primary series of COVID-19 vaccine and a booster shot are required. This Request for Exemption is to be used by MSU Denver students who are not vaccinated (inclusive of booster) and who request to be exempted from the University’s COVID-19 vaccine requirement. Students who are fully vaccinated against COVID-19, including booster, should NOT complete this form.

Individuals who are eligible for a booster (5 months from primary series for Pfizer and Moderna or 2 months from primary series for Johnson & Johnson), but do not intend to receive a booster by the semester deadline must complete a certificate of exemption.

If you are vaccinated and intend to receive a booster, but are not yet eligible due to the dates of your primary vaccine series, do not complete this Request for Exemption. Simply submit your proof of having attained a booster within 30 days of becoming eligible. Once boosted, submit proof using the COVID-19 Compliance Form.

Students that are eligible for a booster but have had a recent COVID-19 infection may receive a booster 2 weeks after their symptoms are resolved, unless advised otherwise by a physician. If this applies, proceed with this exemption request and select Temporary Exemption due to Recent COVID-19 Illness as the exemption reason. Simply submit your proof of having attained a booster within 30 days of becoming eligible. Once boosted, submit proof using the COVID-19 Compliance Form.

Contact Auraria Immunizations at 303-615-9997 for additional information, if needed.

By submitting this request, you understand that you may be subject to future on-going testing requirements, prohibition from campus if warranted by future public health concerns, and/or additional restrictive measures as warranted.

To avoid these potential consequences, you should get vaccinated, including a booster, as this is the best way to protect yourself, others and the campus community from becoming severely ill.

If requesting an exemption, complete the following information by the semester deadline to avoid any future class registration holds.

First name*

Middle initial (if it exists):

Last Name*

Date of Birth*

Student/Staff/Faculty ID#*

Home Address*

Phone Number*

MSU Denver Email Address*

Exemption Type Requested (check one):

Medical

Religious

Personal

*Temporary Exemption due to Recent COVID-19 Illness

If recent COVID-19 illness or treatment, what is your extended eligibility date:

*CDC indicates boosters are recommended 14 days after COVID-19 symptoms have resolved, or as directed by a physician.

Vaccine Status (check one):

I received my primary COVID-19 vaccine(s), but do not intend to get a booster shot

I am unvaccinated and have not received any COVID-19 vaccines

I am not eligible to receive a booster by the deadline because I am requesting a temporary exemption due to recent COVID-19 illness

Statement of Exemption

My signature below affirms that I am requesting a COVID-19 exemption. I am fully aware of, accept and will comply with the above stated potential restrictions if they become necessary and/or any additional future restrictions or requirements that MSU Denver determines necessary. By typing my full name below, I am electronically signing this document and acknowledge that this is a legal equivalent to my handwritten signature.

Patient Signature*

Signature Date*