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.

Vaccines

Reasons

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