Declination Form  

I understand that my exposure to patients at healthcare facilities with the following diseases puts me at risk of acquiring the disease. Most of these diseases are preventable through vaccines. I have had the opportunity to be vaccinated for these diseases; however, I choose at this time to decline the vaccination(s) checked below. I understand that by declining vaccine protection I continue to be at risk of acquiring the disease. I understand that I can receive these vaccinations or tests at any time. 

VACCINATION OR TEST                                                     REASON

( ) Measles, Mumps, Rubella (MMR) Varicella       ___________________________

( ) Hepatitis B                                                         ___________________________

( ) Influenza                                                            ___________________________

( ) Pertussis                                                            ___________________________

( ) Tuberculosis (either test or chest x-ray)          ___________________________

( ) COVID-19                                                          ___________________________  

By submitting this form, I acknowledge that each of my customers defines the required documentation used to manage vendor relationships and that a declination may not satisfy these requirements. As a result, not all health systems will allow badges to print based on declination documents. 

Name: _______________________________

Date: ________________________________

Company: ____________________________

Phone #: _____________________________