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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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FormSONPolio:062018