Nurses Direct: Vaccine Declination
I understand that due to my occupational exposure to blood and other potentially infections materials I may be at risk of acquiring an infectious disease. I have been given the opportunity to be vaccinated from a physician or other facility of my choice at my own expense. If I have already received all of the required vaccines, I agree to provide written documentation to verify to the same Nurses Direct if I will continue my services through Nurses Direct as an employee. I understand that by declining vaccines, I continue to be at risk of acquiring a serious disease. If in the future I continue to have occupational exposure to blood or potentially infectious materials and I want to be vaccinated, I can receive the vaccines from a physician or other facility of my choice at my own expense. With my signature in the appropriate space below, I decline the following vaccines:
I decline to provide documentation of the following vaccines and understand the risks associated with job related exposures:
*
Hep B
MMR
Tetanus/TDaP
Flu
Varicella
COVID (must sign excemption)
Employee personal Email address:
*
example@example.com
Employee Name
*
First Name
Last Name
Today’s Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: