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PHONE: (502) 597-5957 FAX: (502) 597-5818 www.kysu.edu

POLIO IMMUNIZATION WAIVER

□ I RECEIVED the polio vaccine and cannot find records.

□ I NEVER received the polio vaccine.

I WAIVE the polio vaccine. I understand that by declining the vaccine, I continue to be at risk of acquiring polio, a serious disease that can result in death. If, in the future, I continue to have occupational exposure to potentially infectious materials while a student at Kentucky State University.

FormSONPolio:062018