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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: ___



Full name (First, Middle, Last)

## 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



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Submit questions to 502.597.5957 or schoolofnursing@kysu.edu