07/19/21 Mask Exemption Form The Centers for Disease Control

07/19/21

Mask Exemption Form

The Centers for Disease Control (CDC), Kansas Department of Health and Environment

(KDHE), Kansas American Academy of Pediatrics (KAAP), and the Johnson County

Department of Health and Environment (JCDHE) promote mask wearing indoors for children,

youth, and adults who are not fully vaccinated to decrease the spread of COVID-19. Masks may

be removed outdoors.

Please see the reverse side of this form regarding Mask Guidance for School-Aged

Children. Mask exemptions will be considered with completion of this Mask Exemption Form

signed by your primary care provider. SMSD asks that primary care providers and medical

professionals in Kansas work to support and promote masking for unvaccinated adults and

children. Furthermore, please advise youth and their parents on how to increase comfort while

wearing masks.

Health Care Provider Statement:

It has been determined that my patient _____________________________ has a qualified

medical condition or mental health condition that prevents her/him/them from wearing a mask

and therefore, should be exempted from the requirement to wear a mask while in Shawnee

Mission School District buildings.

Please state the medical/mental health condition and risk:

Signature (MD, DO, APRN, PA) _______________________________ date: _______________

RETURN COMPLETED FORM TO THE SCHOOL NURSE OR ADMINISTRATOR

07/19/21

Mask Guidance for School-Aged Children

The CDC recommends the use of non-medical grade cloth face coverings for unvaccinated individuals. Masks are

considered safe for most children and youth over the age of two years. There are very few exceptions for wearing

masks.