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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