I hereby declare that, I, ______________________, as the custodial parent having responsibility for my child, _______________________, who is a minor child enrolled in the __________________________ School, withhold my consent on Tuberculosis screening for _______________________on the grounds that such testing is in violation of my United States of America constitutional 1st Amendment Right to religious freedom. It would be a violation of my religious beliefs to knowingly contaminate the body with inorganic and/or organic substances that can cause injury, illness, or other harm to human well-being.
I further assert the following:
There is no Tuberculosis epidemic in ___________________[city] to warrant the mandate of such testing
There is no Tuberculosis crisis at the ________________________ School to warrant the mandate of such testing
Symptoms commensurate with Tuberculosis are known to be:
Coughing up blood/ Chest infection
Severe weight loss
Loss of appetite
_______________________ has not exhibited any of these of symptoms. There is no reason to suspect that she may be infected with Tuberculosis.
Populations who are at a higher-risk of contracting Tuberculosis are deemed as follows:
Those coming into close contact with persons known or suspected to have TB
Foreign-born persons from areas where TB is common
Residents and employees of high-risk congregate setting
Health care workers who serve high risk patients
Medically underserved, low income populations
High risk racial or ethnic minority populations
Children exposed to adults in high-risk categories
Intravenous Drug Abusers
The Center for Disease Control further breaks down those who are more vulnerable to Tuberculosis as follows:
Those afflicted with HIV/AIDS
Those afflicted with silicosis
Those afflicted with hematological and reticuloendothelial disease
Those afflicted with chronic malabsorption and malnutrition
Those afflicted with diabetes Mellitus
Those who have undergone prolonged steroid therapy
Those who have undergone a solid organ transplantation
Those afflicted with cancer of head and neck
Those afflicted with chronic renal failure
Those possessing low body weight (relative to ideal weight)
_______________________does not fall into any of these categories. The % chance that she may be infected with Tuberculosis is minute and thus, provides no basis to suspect that she may be infected with Tuberculosis.
The Tuberculin Purified Protein Derivative (Mantoux skin test) Tubersol is used to find out whether a person is infected with the Tuberculosis germs (or allergic to the test). It cannot tell whether a person has Tuberculosis disease.
Tubersol contains a human strain of Mycobacterium tuberculosis grown on a protein-free synthetic medium and Phenol, which is carbolic acid. Carbolic acid is a corrosive poisonous crystalline acidic compound C6H5OH present in coal tar and wood tar. Not only is Tubersol not vegetarian (_______________________and I are both vegetarians), but it is composed of a substance that is toxic and poisonous to the body.
Overall, _______________________is a healthy child who poses no serious, infectious health threat to her schoolmates. The only ailments that _______________________ has been afflicted with during the 3 years that she has spent on this Earth are colds. Her overall good health has been confirmed during well-child and non-routine visits to her primary pediatrician and other healthcare givers. She has physically developed at- or ahead of-pace of her peer group.
I have included these assertions to show that _____________________ not being tested for Tuberculosis, poses no threat to the health and well-being of the student body at ________________________ School.
City, State, My Commission expires