KENTUCKY STATE UNIVERSITY
School of Nursing
400 EAST MAIN STREET FRANKFORT, KENTUCKY 40601
PHONE: (502) 597-5957 FAX: (502) 597-5818 www.kysu.edu
POLIO IMMUNIZATION WAIVER
□ I RECEIVED the polio vaccine and cannot find records.
I RECEIVED the polio vaccine and cannot find records
□ I NEVER received the polio vaccine.
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.
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Date
Date
FormSONPolio:062018