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KENTUCKY STATE UNIVERSITY SCHOOL OF NURSING MEDICAL WAIVER (EXEMPTION) FOR VACCINATION
SECTION 1: To be completed by student
Please print
Student ID: ___
Student ID: ___
SECTION 2: To be completed by the primary health care provider (physician or nurse practitioner)
Vaccine(s) Exemption Requested:
Seasonal Flu Vaccine ___ Hepatitis B ___ Other (specify) ___
Medical Reason(s):
Severe Egg or Yeast Allergies ___ Previous Severe Reaction to Vaccination ___
Previous Guillain-Barre syndrome within six (6) weeks of receiving an influenza vaccine ___
Chronic Medical Condition (details required, see below) ___
Other (details required, see below) __
Exemption Period:
Permanent Exemption Request ___
Temporary Exemption Request (time frame) ___
Details:
___ ___ ___
Provider Name (print): ___ Date: ___
Signature (with credentials): ___
Office Stamp/Address & Phone Number
<div style="text-align: center;"><img src="imgs/img_in_image_box_6_0_1109_64.jpg" alt="Image" width="98%" /></div>
Submit questions to 502.597.5957 or schoolofnursing@kysu.edu