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Declination Form <br /> I understand that my exposure to patients at healthcare facilities with the following diseases <br /> puts me at risk of acquiring the disease. Most of these diseases are preventable through <br /> vaccines. I have had the opportunity to be vaccinated for these diseases; however, I choose <br /> at this time to decline the vaccination(s) checked below. I understand that by declining vaccine <br /> protection I continue to be at risk of acquiring the disease. I understand that I can receive these <br /> vaccinations or tests at any time. <br /> VACCINATION OR TEST REASON <br /> ❑ Measles, Mumps, Rubella (MMR) <br /> ❑ Varicella / L <br /> ❑■ Hepatitis B �1 Cil ( <br /> ❑ Influenza <br /> ❑ Pertussis <br /> ❑ Tuberculosis (either test or chest x-ray) <br /> ❑ Other: <br /> �qBy submitting this form, I acknowledge that each of my customers defines the required <br /> documentation used to manage vendor relationships and that a declination may not satisfy <br /> these requirements. <br /> Name: Cot d' Val eY Date: <br /> Company: Phone #: <br />