vaccine declination form

Name Title School/College/Division Department Access ID Phone No. I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring seasonal influenza. %PDF-1.7 %���� 30 0 obj <>stream h�bbd``b`J~@��H0� �� �D Q���q�DP ��jcd� c`$@�g � �� h�b``d``�a```�>ɀ HEPATITIS A VACCINE DECLINATION I, (print) _____, understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis A (HAV). Signature Date . The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and … 0

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I:\Bio_Safety\FORMS\Vaccine forms\Forms in Word version\Varicella Vaccine AcceptDecline_2014.doc Updated 5/9/2014 Varicella Zoster Vaccine Acceptance/Declination Form %%EOF 90 0 obj <>/Filter/FlateDecode/ID[<2CCCC99C1647A24B829253F118285159><991495E080EAF144BB8250CFFBFA0323>]/Index[71 30]/Info 70 0 R/Length 99/Prev 103549/Root 72 0 R/Size 101/Type/XRef/W[1 3 1]>>stream Please check all that apply. Print name Department . Signature Date . endstream endobj 11 0 obj <> endobj 12 0 obj <> endobj 13 0 obj <>stream For parents who refuse one or more recommended immunizations, document your conversation and the provision of the VIS(s), have a parent sign the Refusal to Vaccinate form, and keep the form in the patient’s medical record. Influenza Vaccination of Health Care Providers in Long-Term Care: Letter from the Assistant Secretary for Health pdf icon [302 KB, 2 pages]

I decline the vaccination at this time. MMR Vaccine Declination (Measles, Mumps and Rubella Vaccine) I understand that due to occupational exposure, I may be at risk of acquiring measles, mumps or rubella. Fact sheets and other resources. endstream endobj startxref The statement can only be signed by the Declination of Influenza Vaccination Form pdf icon [65 KB, 1 page] external icon. 350 0 obj <> endobj Knowing these facts, I choose to decline vaccination at this time.

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I can receive the Hepatitis A vaccination series, at no cost to me. Most people with . I may change my mind and accept vaccination later, if vaccine is available. Seasonal Flu Declination Form Form must be completed and uploaded to CastleBranch . ` �� I have been given the opportunity to be vaccinated with MMR (measles, mumps and rubella) vaccine, at no charge to myself. 0 DECLINATION WAIVER FOR THE INFLUENZA VACCINE Please complete this form and send it to your HR Consultant Campus Health Center and to the . Parents/guardians may seek the advice of others, including their child’s health care provider (Woodruff, 1996). Please check all that apply. Because the idea of vaccinating children at school may be unfamiliar to some parents/guardians, there may be reluctance to consent to influenza vaccination at school.

%%EOF %PDF-1.6 %���� endstream endobj startxref endstream endobj startxref Print name Department . 376 0 obj <>stream h�bbd```b``Z"��If��"YπH�n0�4�� ��`qG0{"X�-�d��Z`s4A�ė`�e�$�@�K ��k`��$���� 0 �7 I have read and fully understand the information on this declination form.

h�bbd```b``���@$�n�"��H�S �GDr������; �w/X�DFw IƷU`s.�H�5@��. However, I decline MMR vaccination at this time. �g0 �a I may change my mind and accept vaccination later, if vaccine is available. Hepatitis B recovers completely but about 5-10 % of infected individuals become chronic carriers of the Supervisor’s Name Supervisor’s Email Address Objection to obtain the influenza vaccine is based on the following reason(s).

%PDF-1.6 %���� 10 0 obj <> endobj Supervisor’s Name Supervisor’s Email Address Objection to obtain the influenza vaccine is based on the following reason(s). 217 0 obj <>stream I believe I will get the flu if I get the shot. � I understand that my exposure to patients at HCA healthcare facilities with the following vaccine preventable diseases puts me at risk of acquiring the disease. For parents who refuse one or more recommended immunizations, document your conversation and the provision of the VIS(s), have a parent sign the Refusal to Vaccinate form, and keep the form in the patient’s medical record. 2019-2020 INFLUENZA VACCINE DECLINATION FORM PRINT NAME: _____ DOB: _____ I DO NOT WANT A FLU SHOT I acknowledge that I am aware of the following facts: • Influenza is a serious respiratory disease; on average, 36,000 Americans die every year from influenza-related causes. Name Title School/College/Division Department Access ID Phone No. 0 In the U.S., children are vaccinated primarily in their pediatrician’s or family doctor’s office (Groom, 2007). h�bbd``b`���S=�`y hޜ�ko����%��`�=N�Ԯ�ҘP;b�/5]D��m�v�{�q.��c�;>�.

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