Division of Continuing Studies Online Bachelor of General Studies DISTANCE EDUCATION STUDENT INCOMPLETE IMMUNIZATION WAIVER 1. The University of Nebraska at Omaha requires all students born after January 1, 1957 to provide proof of immunization record of 2 MMR shots. 2. Measles (rubeola) is often a severe disease, frequently complicated by middle ear infection or bronchopneumonia. Encephalitis occurs in approximately one of every 1,000 reported cases; survivors of this complication often have permanent brain damage and mental retardation. Death, usually from respiratory and neurologic causes, occurs in one of every 1,000 reported measles cases. The risk of death is greater for infants and adults than for children and adolescents. 3. As a non-immunized distance education student I agree: a. I will not be on the UNO campus b. I understand this waiver must be completed every two years; failure to do so will prevent me from registering for classes. c. The alternative option is proof of immunization by turning in dates of immunization or laboratory proof of immunity for rubeola. Name: (please print) ________________________________________________________________________ Student’s Signature: _________________________________________ ID#: __ __ __ __ __ __ __ __ Daytime Phone #:___________________ Date of Birth: _______________________________________________ Address: ___________________________________________________ Date: ______________________________________________________
University of Nebraska at Omaha Student Health Services 6001 Dodge Street Milo Bail Student Center, 1st Floor Omaha, NE 68182-0301 Fax 402-554-2387
This waiver will expire two (2) years from the above date
Rev. 1/2008