Form CCA-1163A Affidavit of Immunization Exemption for Household Members Age 13 and Younger - Arizona

What Is Form CCA-1163A?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form CCA-1163A?
A: Form CCA-1163A is the Affidavit of Immunization Exemption for Household Members Age 13 and Younger.

Q: Who needs to fill out Form CCA-1163A?
A: Form CCA-1163A needs to be filled out by household members age 13 and younger who are seeking immunization exemption.

Q: Why would someone need to fill out Form CCA-1163A?
A: Someone may need to fill out Form CCA-1163A if they have a religious or personal belief exemption to immunization for household members age 13 and younger.

Q: What information is required on Form CCA-1163A?
A: Form CCA-1163A requires information such as the name and age of the household member, the parent or guardian's contact information, and the reason for the immunization exemption.

Q: Is there a deadline for submitting Form CCA-1163A?
A: Yes, Form CCA-1163A must be submitted to the child's school or child care facility by the enrollment or attendance deadline.

Q: Can the immunization exemption be revoked?
A: Yes, the immunization exemption can be revoked if there is an outbreak of a vaccine-preventable disease in the community.

Q: Are there any exceptions to the immunization exemption?
A: Yes, there are exceptions to the immunization exemption for certain diseases that may pose a high risk to public health.

Q: Can I get a copy of Form CCA-1163A for my records?
A: Yes, you can make a copy of Form CCA-1163A for your records before submitting it.