Download Pneumococcal Vaccine Declination

Pneumococcal Vaccine Declination
The Pennsylvania Long Term Care Resident and Employee Immunization Act requires that all employees and
students participating in educational experiences in long term care or rehabilitation facilities be immunized
for pneumococcal disease. It is a condition of clinical site training unless the following criteria apply:
1. The vaccine is contraindicated.
2. It is against the student’s religious beliefs.
3. The student refuses the vaccine after being fully informed of the health risks of such actions.
Pneumococcal Polysaccharide Vaccine:
The CDC recommends the Pneumococcal Polysaccharide Vaccine (PPV) to help prevent certain types of
pneumonia.
PPV is recommended for persons 65 years of age or older, who have certain long term health problems, a
weakened immune system, or other health concerns. Please see http://www.cdc.gov/vaccines/vpdvac/pneumo/vacc-in-short.htm for a complete list.
Vaccine clinic:
Alvernia University does not offer a pneumococcal vaccine clinic. However, if you choose to receive this
immunization, the Health & Wellness Center can vaccinate you. The approximate cost of the vaccine is
$90.00. Please contact the Health & Wellness Center to schedule an appointment, 610-568-1467.
Pneumococcal Polysaccharide Vaccine:
, have read the Pneumococcal Polysaccharide Vaccine
I,
(Student Name)
Information Sheet and I hereby decline the Pneumococcal Polysaccharide vaccine at this time.
Student Signature
Date
Witness Signature
Major
11/30/2016