VACCINATION DECLINATION OR OBJECTION FORM

As a patient safety and health care personnel safety initiative, Post Acute Medical is requiring vaccinations for the following vaccine-preventable diseases: MMR, Varicella, Tdap, Influenza, and Meningococcal (for microbiologists only). This is similar to other vaccinations that Post Acute Medical requires as a condition of employment. Certain vaccinations have been recommended by the Centers for Disease Control for health care personnel and have been shown to be effective in protecting patients from these illnesses and complications related to them. Increasingly, national professional, health care and infection prevention organizations are recommending that health care organizations require certain vaccinations to protect the health and safety of patients, employees, patient and employee family members, and the community as a whole from these diseases.

I understand that as a patient safety and health care personnel safety initiative, Post Acute Medical has implemented a policy for vaccine preventable diseases. I have read the Vaccination Policy and understand the policy as written. I have received information on the benefits and risks of the vaccinations, and at this time I choose to decline/object to the following vaccines for the following reason.

Print name

DOB

Vaccines Vaccines Varicella MMR Tdap Influenza Meningococcal

Objection to vaccine for reasons of conscience. The individual identified above is requesting to be exempt from the above mentioned vaccines(check all that apply) for conscientious objections the following for the following reason listed below: PLEASE TYPE YOUR OBJECTION HERE

Employee Signature

Religious Objection. The individual identified above is requesting to be exempt from the above mentioned vaccines (check all that apply) for religious reasons. Please confirm that the individual follows religious beliefs that would qualify for an exemption by completing the information below. Description of religious doctrine that is contrary to vaccinations: I certify that the above individual practices a religion where vaccinations are contraindicated according to doctrine or accepted religious practices. I understand that I could be contacted for additional clarification.

Name of Clergy:

Signature of Clergy:

Employee Signature:

Email Address

Medical Contraindication. Medical exemption from vaccinations is allowed for contraindications or precautions identified by the Centers for Disease Control and Prevention. Please complete the form below to request medical exemption for your patient. My patient should not be vaccinated against the above mentioned vaccines (check all that apply) for the following reasons:

Reasons Reasons Temporary Medical Condition Permanent Medical Condition

Post Acute Medical’s vaccination policy. I understand that I could be contacted for additional clarification. Name of Medical Practitioner (MD, DO, APRN, PA):

Signature:

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