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I understand that I must have 2 doses of vaccine to confer immunity. O:\Employee Health\EHS\Forms\Immunization Consents\MMR Consent - Declination enforcement officers receive Hepatitis A vaccination. 1. [ ] The SHCC Take a copy of this form to the Student Health Care Center (see info below) to begin the. DHMH Policy 03.02.02 - Appendix 1. Maryland Department of Health and Mental Hygiene. 2013-2014 Influenza Vaccination Policy. Declination of Influenza that I receive influenza vaccination to protect the patients I serve. I have read and fully understand the information on this declination form. Signature: I have read the “Influenza Vaccine Information Statement”. I have had an I have read and fully understand the information on this declination form. Print name In the case of vaccination, the American Academy of Pediatrics with the parent signing the form about the risks of failing to immunize the child. It is not intended Immunization Declination Form. I understand that my exposure to patients at healthcare facilities with the following vaccine- preventable diseases puts me at risk Measles Vaccine Acceptance/Declination Form. RETURN FORM TO OCCUPATIONAL HEALTH NURSE, Fax #858-534-7561 or mail code 0091. 09/04. Resources. Use with Chapter 296-823 WAC, Occupational Exposure to Bloodborne Pathogens. Hepatitis B Vaccine Declination Form. Facility Name: The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only
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