[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 170.16, "t": 755.76, "r": 441.6, "b": 714.96 }, "text": "KENTUCKY STATE UNIVERSITY\nSCHOOL OF NURSING\nMEDICAL WAIVER (EXEMPTION) FOR VACCINATION", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TITLE", "location": { "l": 33.84, "t": 701.04, "r": 248.16, "b": 687.84 }, "text": "SECTION 1: To be completed by student", "reading_order": 1, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 674.16, "r": 99.36, "b": 661.44 }, "text": "Please print", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 647.52, "r": 289.68, "b": 635.28 }, "text": "Student ID: ___", "reading_order": 3 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 36, "t": 655.8, "r": 288.96, "b": 636.24 }, "text": "Full name (First, Middle, Last", "field_kind": "text", "label": "Full name (First, Middle, Last", "pdf_field_name": "Full name First Middle Last", "pdf_field_type": "Text", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 34.32, "t": 633.6, "r": 187.68, "b": 620.4 }, "text": "Full name (First, Middle, Last)", "reading_order": 5 }, { "page": 1, "type": "TEXT", "location": { "l": 358.08, "t": 647.52, "r": 552.24, "b": 634.08 }, "text": "Student ID: ___", "reading_order": 6 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 423.96, "t": 655.8, "r": 550.56, "b": 636.24 }, "text": "Student ID", "field_kind": "text", "label": "Student ID", "pdf_field_name": "Student ID", "pdf_field_type": "Text", "reading_order": 7 }, { "page": 1, "type": "TITLE", "location": { "l": 33.84, "t": 593.28, "r": 553.68, "b": 579.6 }, "text": "SECTION 2: To be completed by the primary health care provider (physician or nurse practitioner)", "reading_order": 8, "level": 2 }, { "page": 1, "type": "TITLE", "location": { "l": 34.32, "t": 566.64, "r": 218.64, "b": 552.96 }, "text": "Vaccine(s) Exemption Requested:", "reading_order": 9, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 539.76, "r": 547.68, "b": 525.6 }, "text": "Seasonal Flu Vaccine ___ Hepatitis B ___ Other (specify) ___", "reading_order": 10 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 152.88, "t": 547.92, "r": 174.84, "b": 528.36 }, "text": "Seasonal Flu Vaccine", "field_kind": "text", "label": "Seasonal Flu Vaccine", "pdf_field_name": "Seasonal Flu Vaccine", "pdf_field_type": "Text", "reading_order": 11 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 238.32, "t": 547.92, "r": 260.4, "b": 528.36 }, "text": "Hepatitis B", "field_kind": "text", "label": "Hepatitis B", "pdf_field_name": "Hepatitis B", "pdf_field_type": "Text", "reading_order": 12 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 370.2, "t": 547.92, "r": 546.24, "b": 528.36 }, "text": "Other (specify", "field_kind": "text", "label": "Other (specify", "pdf_field_name": "Other specify", "pdf_field_type": "Text", "reading_order": 13 }, { "page": 1, "type": "TITLE", "location": { "l": 34.08, "t": 512.4, "r": 139.68, "b": 498.96 }, "text": "Medical Reason(s):", "reading_order": 14, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 33.12, "t": 485.28, "r": 543.12, "b": 471.6 }, "text": "Severe Egg or Yeast Allergies ___ Previous Severe Reaction to Vaccination ___", "reading_order": 15 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 192, "t": 493.8, "r": 225.12, "b": 474.24 }, "text": "Severe Egg or Yeast Allergies", "field_kind": "text", "label": "Severe Egg or Yeast Allergies", "pdf_field_name": "Severe Egg or Yeast Allergies", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 508.08, "t": 493.8, "r": 541.08, "b": 474.24 }, "text": "Previous Severe Reaction to Vaccination", "field_kind": "text", "label": "Previous Severe Reaction to Vaccination", "pdf_field_name": "Previous Severe Reaction to Vaccination", "pdf_field_type": "Text", "reading_order": 17 }, { "page": 1, "type": "TEXT", "location": { "l": 33.36, "t": 464.88, "r": 530.4, "b": 451.68 }, "text": "Previous Guillain-Barre syndrome within six (6) weeks of receiving an influenza vaccine ___", "reading_order": 18 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 494.16, "t": 472.92, "r": 527.4, "b": 454.08 }, "text": "Previous Guillain-Barre syndrome within six (6) weeks of receiving an influenza vaccine", "field_kind": "text", "label": "Previous Guillain-Barre syndrome within six (6) weeks of receiving an influenza vaccine", "pdf_field_name": "Previous GuillainBarre syndrome within six 6 weeks of receiving an influenza vaccine", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 444.72, "r": 367.92, "b": 431.28 }, "text": "Chronic Medical Condition (details required, see below) ___", "reading_order": 20 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 338.04, "t": 452.76, "r": 365.64, "b": 433.8 }, "text": "Chronic Medical Condition (details required, see below", "field_kind": "text", "label": "Chronic Medical Condition (details required, see below", "pdf_field_name": "Chronic Medical Condition details required see below", "pdf_field_type": "Text", "reading_order": 21 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 424.8, "r": 253.68, "b": 410.64 }, "text": "Other (details required, see below) __", "reading_order": 22 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 223.92, "t": 432.48, "r": 251.52, "b": 413.52 }, "text": "Other (details required, see below", "field_kind": "text", "label": "Other (details required, see below", "pdf_field_name": "Other details required see below", "pdf_field_type": "Text", "reading_order": 23 }, { "page": 1, "type": "TITLE", "location": { "l": 34.08, "t": 404.4, "r": 133.44, "b": 390.96 }, "text": "Exemption Period:", "reading_order": 24, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 33.84, "t": 384.24, "r": 236.64, "b": 370.32 }, "text": "Permanent Exemption Request ___", "reading_order": 25 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 206.52, "t": 392.64, "r": 234.12, "b": 373.08 }, "text": "Permanent Exemption Request", "field_kind": "text", "label": "Permanent Exemption Request", "pdf_field_name": "Permanent Exemption Request", "pdf_field_type": "Text", "reading_order": 26 }, { "page": 1, "type": "TEXT", "location": { "l": 33.84, "t": 363.84, "r": 360.96, "b": 349.92 }, "text": "Temporary Exemption Request (time frame) ___", "reading_order": 27 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 270.48, "t": 372.36, "r": 358.68, "b": 352.8 }, "text": "Temporary Exemption Request (time frame", "field_kind": "text", "label": "Temporary Exemption Request (time frame", "pdf_field_name": "Temporary Exemption Request time frame", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 1, "type": "TITLE", "location": { "l": 34.56, "t": 343.44, "r": 75.84, "b": 331.2 }, "text": "Details:", "reading_order": 29, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 321.12, "r": 576, "b": 249.36 }, "text": "___\n___\n___", "reading_order": 30 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 36, "t": 331.2, "r": 574.92, "b": 312.36 }, "text": "Details [1]", "field_kind": "text", "label": "Details [1]", "pdf_field_name": "Details 1", "pdf_field_type": "Text", "reading_order": 31 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 36, "t": 311.64, "r": 574.92, "b": 292.08 }, "text": "Details [2]", "field_kind": "text", "label": "Details [2]", "pdf_field_name": "Details 2", "pdf_field_type": "Text", "reading_order": 32 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 36, "t": 291.36, "r": 574.92, "b": 271.8 }, "text": "Details [3]", "field_kind": "text", "label": "Details [3]", "pdf_field_name": "Details 3", "pdf_field_type": "Text", "reading_order": 33 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 36, "t": 271.2, "r": 399, "b": 251.64 }, "text": "Details [4]", "field_kind": "text", "label": "Details [4]", "pdf_field_name": "Details 4", "pdf_field_type": "Text", "reading_order": 34 }, { "page": 1, "type": "TEXT", "location": { "l": 34.8, "t": 222, "r": 567.6, "b": 208.8 }, "text": "Provider Name (print): ___ Date: ___", "reading_order": 35 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 153.36, "t": 230.76, "r": 345.96, "b": 211.2 }, "text": "Provider Name (print", "field_kind": "text", "label": "Provider Name (print", "pdf_field_name": "Provider Name print", "pdf_field_type": "Text", "reading_order": 36 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 427.68, "t": 230.76, "r": 565.2, "b": 211.2 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date", "pdf_field_type": "Text", "reading_order": 37 }, { "page": 1, "type": "TEXT", "location": { "l": 34.32, "t": 181.92, "r": 448.56, "b": 168 }, "text": "Signature (with credentials): ___", "reading_order": 38 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 171.12, "t": 190.2, "r": 446.4, "b": 170.64 }, "text": "Signature (with credentials", "field_kind": "signature", "label": "Signature (with credentials", "pdf_field_name": "Signature with credentials", "pdf_field_type": "Signature", "reading_order": 39 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 121.44, "r": 250.32, "b": 107.76 }, "text": "Office Stamp/Address & Phone Number", "reading_order": 40 }, { "page": 1, "type": "TEXT", "location": { "l": 304.56, "t": 159.84, "r": 566.88, "b": 149.04 }, "text": "
\"Image\"
\n", "reading_order": 41 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 307.44, "t": 149.04, "r": 566.04, "b": 87.36 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined", "pdf_field_type": "Text", "reading_order": 42 }, { "page": 1, "type": "TEXT", "location": { "l": 154.8, "t": 80.64, "r": 456.48, "b": 67.92 }, "text": "Submit questions to 502.597.5957 or schoolofnursing@kysu.edu", "reading_order": 43 } ] } ]