Md. Code Regs. 10.06.05.06 - Waiver Form

A. A waiver form for an individual 18 years old or older shall:

(1) State that the individual:

(a) Is 18 years old or older;

(b) Has received and reviewed the information provided by the institution of higher education on the risk of meningococcal disease and the availability and effectiveness of meningococcal vaccine; and

(c) Chooses to waive the receipt of meningococcal vaccine; and

(2) Provide spaces for the:

(a) Printed name of the individual;

(b) Signature of the individual; and

(c) Date.

B. A waiver form for an individual younger than 18 years old shall:

(1) State that:

(a) The individual is younger than 18 years old;

(b) The parent or guardian of the individual has received and reviewed the information provided by the institution of higher education on the risk of meningococcal disease and the availability and effectiveness of meningococcal vaccine; and

(c) The parent or guardian of the individual chooses to waive the receipt of meningococcal vaccine for the individual; and

(2) Provide spaces for the:

(a) Printed name of the individual;

(b) Printed name of the parent or guardian;

(c) Signature of the parent or guardian; and

(d) Date.

Notes

Md. Code Regs. 10.06.05.06