(a) Exemption from the use of a child passenger restraint system for medical reasons may be obtained upon written certification by a physician that use of a child passenger restraint system is impractical. The certification must be made on a form developed by the Department which will require the following information:

1. (1) The physician’s name and practice address.
2. (2) The date the form was completed.
3. (3) The name, age and weight of the child.
4. (4) The medical or physical reasons that the use of a particular child passenger restraint system or systems is impractical.
5. (5) A recommendation of the type of passenger restraint the child should be fastened into or a statement that no appropriate passenger restraint system is known.
6. (6) A recommendation regarding the length of time the exemption should extend, or a statement of the conditions under which the exemption should be lifted.
7. (7) Other information deemed relevant by the physician, such as whether the child can be fastened into the child passenger restraint system but for only limited periods of time.