Download meningococcal vaccine declination form

Form 513
V20111104
MENINGOCOCCAL VACCINE DECLINATION FORM
I understand that due to my occupational exposure to infected person or other potentially
infectious materials, I may be at risk of acquiring meningococcal disease. I have been given the
opportunity to be vaccinated with a meningococcal vaccine at no cost to me. However, I decline
Meningococcal vaccination at this time. I understand that by declining this vaccine, I continue to
be at risk of acquiring meningococcal, a serious disease. If in the future I continue to have
occupational exposure to meningococcal bacteria and I want to be vaccinated with a
meningococcal vaccine, I can receive the vaccine at no charge to me.
Signature - Employee
Date
Witness
Date
Please return completed form to Occupational Safety and Health.
6720-A Rockledge Drive · Suite 100 · Bethesda, Maryland 20817 · OSH Phone (240) 694-4050 · OSH Fax (240) 314-7330 · www.hjf.org