KENTUCKY STATE UNIVERSITY SCHOOL OF NURSING MEDICAL WAIVER (EXEMPTION) FOR VACCINATION
SECTION 1: To be completed by student
Please print
Student ID: ___
Full name (First, Middle, Last
Full name (First, Middle, Last)
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) ___
Seasonal Flu Vaccine
Hepatitis B
Other (specify
Medical Reason(s):
Severe Egg or Yeast Allergies ___ Previous Severe Reaction to Vaccination ___
Severe Egg or Yeast Allergies
Previous Severe Reaction to Vaccination
Previous Guillain-Barre syndrome within six (6) weeks of receiving an influenza vaccine ___
Previous Guillain-Barre syndrome within six (6) weeks of receiving an influenza vaccine
Chronic Medical Condition (details required, see below) ___
Chronic Medical Condition (details required, see below
Other (details required, see below) __
Other (details required, see below
Exemption Period:
Permanent Exemption Request ___
Permanent Exemption Request
Temporary Exemption Request (time frame) ___
Temporary Exemption Request (time frame
Details:
___ ___ ___
Details [1]
Details [2]
Details [3]
Details [4]
Provider Name (print): ___ Date: ___
Provider Name (print
Date
Signature (with credentials): ___
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>
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Submit questions to 502.597.5957 or schoolofnursing@kysu.edu
FormSONExempt: 06/2018