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!a <br /> AWL <br /> Immunization Declination Form <br /> I understand that my exposure to patients at healthcare facilities with the following vaccine- <br /> preventable diseases puts me at risk of acquiring the disease. I have had the opportunity to be <br /> vaccinated, however, I choose to decline the vaccination(s) checked below at this time. I <br /> understand that by declining vaccine protection I continue to be at risk of acquiring the <br /> disease. <br /> In the event of exposure 1 understand that I may be requested to not visit the facility for at least <br /> the incubation period of the disease to which I have been exposed. In some cases that may <br /> be for a period of up to a month. <br /> Type Reason <br /> ❑ Measles, Mumps, Rubella (MMR) <br /> ❑ Varicella (VZW) <br /> Hepatitis B <br /> ❑ Influenza <br /> ❑ H1 N1 <br /> ❑ Tetanus / Pertussis /Tdap <br /> ❑ TB ❑ Chest X-Ray <br /> ❑ Other <br /> By submitting this form, I acknowledge that each of my customers defines the required <br /> documentation used to manage vendor relationships, and that a vaccination declination may <br /> not satisfy these requirements. <br /> e� <br /> Signed: '� Date: <br /> Printed <br /> Name: Title: <br /> Company: Phone #: ( ,� e-= M 61f <br /> v e n d o r N-,-,t t oi�:, <br /> 0 Copyright 2010 Vendormate,Inc.All rights reserved. <br />