Immunizations Declination

Immunizations are required for hands-on experiences here at Aultman. Required immunizations, except for TB, can be waived by signing this form.

Hepatitis B
- Documented proof of a completed Hepatitis B series
- Positive Hepatitis B blood test titer.

MMR
- Documented proof of two immunizations
- Positive Rubella, Rubeola blood test titer.

Tdap
- Documentation and date of last tetanus vaccine.
*Please note: As of 2007, the adult Tdap vaccine became available. If you had just a Tetanus, diphtheria vaccine (Td) prior to this becoming available, you will need to get a new tetanus vaccine which includes Tetanus, diphtheria and pertussis (Tdap).

- If you have received the Tdap vaccine: then one Td vaccine every 10 years is required.

Varicella
- Documentation of receiving the Varicella vaccine
- Positive blood test titer.

Tuberculosis Testing **CAN NOT BE WAIVED**
- Documentation of a 2-step Mantoux test (TB) within the last 12 months
- 2-step Mantoux test (TB) with 1-step Mantoux test (TB) every year after

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Email
What student experience are you partaking in?

What student experience are you partaking in? Clinicals Internship Observation
What school do you attend?

If you're an non-student doing an observation put N/A.
What program are you in?

“I’m in the Stark State LPN Clinical Group” or “I’m interning in Anesthesia”, etc.
Start Date Start Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Hepatitis B Vaccine
VACCINE INFORMATION STATEMENT Hepatitis B Vaccine What You Need to Know Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis 1 What is hepatitis B? Hepatitis B is a serious infection that affects the liver. It is caused by the hepatitis B virus. In 2009, about 38,000 people became infected with hepatitis B. Each year about 2,000 to 4,000 people die in the United States from cirrhosis or liver cancer caused by hepatitis B. Hepatitis B can cause: Acute (short-term) illness. This can lead to: loss of appetite • diarrhea and vomiting tiredness • jaundice (yellow skin or eyes) pain in muscles, joints, and stomach Acute illness, with symptoms, is more common among adults. Children who become infected usually do not have symptoms. Chronic (long-term) infection. Some people go on to develop chronic hepatitis B infection. Most of them do not have symptoms, but the infection is still very serious, and can lead to: liver damage (cirrhosis) • liver cancer • death Chronic infection is more common among infants and children than among adults. People who are chronically infected can spread hepatitis B virus to others, even if they don’t look or feel sick. Up to 1.4 million people in the United States may have chronic hepatitis B infection. Hepatitis B virus is easily spread through contact with the blood or other body fluids of an infected person. People can also be infected from contact with a contaminated object, where the virus can live for up to 7 days. A baby whose mother is infected can be infected at birth; Children, adolescents, and adults can become infected by: contact with blood and body fluids through breaks in the skin such as bites, cuts, or sores; contact with objects that have blood or body fluids on them such as toothbrushes, razors, or monitoring and treatment devices for diabetes; having unprotected sex with an infected person; sharing needles when injecting drugs; being stuck with a used needle. Hepatitis B vaccine: 2 Why get vaccinated? Hepatitis B vaccine can prevent hepatitis B, and the serious consequences of hepatitis B infection, including liver cancer and cirrhosis. Hepatitis B vaccine may be given by itself or in the same shot with other vaccines. Routine hepatitis B vaccination was recommended for some U.S. adults and children beginning in 1982, and for all children in 1991. Since 1990, new hepatitis B infections among children and adolescents have dropped by more than 95%—and by 75% in other age groups. Vaccination gives long-term protection from hepatitis B infection, possibly lifelong. 3 Who should get hepatitis B vaccine and when? Children and adolescents Babies normally get 3 doses of hepatitis B vaccine: 1st Dose: Birth 2nd Dose: 1-2 months of age 3rd Dose: 6-18 months of age Some babies might get 4 doses, for example, if a combination vaccine containing hepatitis B is used. (This is a single shot containing several vaccines.) The extra dose is not harmful. Anyone through 18 years of age who didn’t get the vaccine when they were younger should also be vaccinated. Adults All unvaccinated adults at risk for hepatitis B infection should be vaccinated. This includes: sex partners of people infected with hepatitis B, men who have sex with men, people who inject street drugs, people with more than one sex partner, people with chronic liver or kidney disease, people under 60 years of age with diabetes, people with jobs that expose them to human blood or other body fluids, household contacts of people infected with hepatitis B, residents and staff in institutions for the developmentally disabled, kidney dialysis patients, people who travel to countries where hepatitis B is common, people with HIV infection. Other people may be encouraged by their doctor to get hepatitis B vaccine; for example, adults 60 and older with diabetes. Anyone else who wants to be protected from hepatitis B infection may get the vaccine. Pregnant women who are at risk for one of the reasons stated above should be vaccinated. Other pregnant women who want protection may be vaccinated. Adults getting hepatitis B vaccine should get 3 doses—with the second dose given 4 weeks after the first and the third dose 5 months after the second. Your doctor can tell you about other dosing schedules that might be used in certain circumstances. 4 Who should not get hepatitis B vaccine? Anyone with a life-threatening allergy to yeast, or to any other component of the vaccine, should not get hepatitis B vaccine. Tell your doctor if you have any severe allergies. Anyone who has had a life-threatening allergic reaction to a previous dose of hepatitis B vaccine should not get another dose. Anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait until they recover before getting the vaccine. Your doctor can give you more information about these precautions. Note: You might be asked to wait 28 days before donating blood after getting hepatitis B vaccine. This is because the screening test could mistake vaccine in the bloodstream (which is not infectious) for hepatitis B infection. 5 What are the risks from hepatitis B vaccine? Hepatitis B is a very safe vaccine. Most people do not have any problems with it. The vaccine contains non-infectious material, and cannot cause hepatitis B infection. Some mild problems have been reported: Soreness where the shot was given (up to about 1 person in 4). Temperature of 99.9°F or higher (up to about 1 person in 15). Severe problems are extremely rare. Severe allergic reactions are believed to occur about once in 1.1 million doses. A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine causing serious harm, or death, is extremely small. More than 100 million people in the United States have been vaccinated with hepatitis B vaccine. 6 What if there is a serious reaction? What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS is only for reporting reactions. They do not give medical advice. 7 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation. 8 How can I learn more? Ask your doctor. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines Vaccine Information Statement (Interim) Hepatitis B Vaccine Office Use Only 2/2/2012 42 U.S.C. § 300aa-26
I have read the above information on the Hepatitis B Vaccine and I decline vaccination at this time.
Tdap Vaccine
VACCINE INFORMATION STATEMENT Tdap Vaccine (Tetanus, Diphtheria, and Pertussis) Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis What You Need to Know Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis 1 Why get vaccinated? 2 Tdap vaccine Tetanus, diphtheria and pertussis can be very serious diseases, even for adolescents and adults. Tdap vaccine can protect us from these diseases. TETANUS (Lockjaw) causes painful muscle tightening and stiffness, usually all over the body. It can lead to tightening of muscles in the head and neck so you can’t open your mouth, swallow, or sometimes even breathe. Tetanus kills about 1 out of 5 people who are infected. DIPHTHERIA can cause a thick coating to form in the back of the throat. It can lead to breathing problems, paralysis, heart failure, and death. PERTUSSIS (Whooping Cough) causes severe coughing spells, which can cause difficulty breathing, vomiting and disturbed sleep. It can also lead to weight loss, incontinence, and rib fractures. Up to 2 in 100 adolescents and 5 in 100 adults with pertussis are hospitalized or have complications, which could include pneumonia or death. These diseases are caused by bacteria. Diphtheria and pertussis are spread from person to person through coughing or sneezing. Tetanus enters the body through cuts, scratches, or wounds. Before vaccines, the United States saw as many as 200,000 cases a year of diphtheria and pertussis, and hundreds of cases of tetanus. Since vaccination began, tetanus and diphtheria have dropped by about 99% and pertussis by about 80%. Tdap vaccine can protect adolescents and adults from tetanus, diphtheria, and pertussis. One dose of Tdap is routinely given at age 11 or 12. People who did not get Tdap at that age should get it as soon as possible. Tdap is especially important for health care professionals and anyone having close contact with a baby younger than 12 months. Pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis. Infants are most at risk for severe, life-threatening complications from pertussis. A similar vaccine, called Td, protects from tetanus and diphtheria, but not pertussis. A Td booster should be given every 10 years. Tdap may be given as one of these boosters if you have not already gotten a dose. Tdap may also be given after a severe cut or burn to prevent tetanus infection. Your doctor can give you more information. Tdap may safely be given at the same time as other vaccines. 3 Some people should not get this vaccine If you ever had a life-threatening allergic reaction after a dose of any tetanus, diphtheria, or pertussis containing vaccine, OR if you have a severe allergy to any part of this vaccine, you should not get Tdap. Tell your doctor if you have any severe allergies. If you had a coma, or long or multiple seizures within 7 days after a childhood dose of DTP or DTaP, you should not get Tdap, unless a cause other than the vaccine was found. You can still get Td. Talk to your doctor if you: have epilepsy or another nervous system problem, had severe pain or swelling after any vaccine containing diphtheria, tetanus or pertussis, ever had Guillain-Barré Syndrome (GBS), aren’t feeling well on the day the shot is scheduled. 4 Risks of a vaccine reaction With any medicine, including vaccines, there is a chance of side effects. These are usually mild and go away on their own, but serious reactions are also possible. Brief fainting spells can follow a vaccination, leading to injuries from falling. Sitting or lying down for about 15 minutes can help prevent these. Tell your doctor if you feel dizzy or light-headed, or have vision changes or ringing in the ears. Mild problems following Tdap (Did not interfere with activities) Pain where the shot was given (about 3 in 4 adolescents or 2 in 3 adults) Redness or swelling where the shot was given (about 1 person in 5) Mild fever of at least 100.4°F (up to about 1 in 25 adolescents or 1 in 100 adults) Headache (about 3 or 4 people in 10) Tiredness (about 1 person in 3 or 4) Nausea, vomiting, diarrhea, stomach ache (up to 1 in 4 adolescents or 1 in 10 adults) Chills, body aches, sore joints, rash, swollen glands (uncommon) Moderate problems following Tdap (Interfered with activities, but did not require medical attention) Pain where the shot was given (about 1 in 5 adolescents or 1 in 100 adults) Redness or swelling where the shot was given (up to about 1 in 16 adolescents or 1 in 25 adults) Fever over 102°F (about 1 in 100 adolescents or 1 in 250 adults) Headache (about 3 in 20 adolescents or 1 in 10 adults) Nausea, vomiting, diarrhea, stomach ache (up to 1 or 3 people in 100) Swelling of the entire arm where the shot was given (up to about 3 in 100). Severe problems following Tdap (Unable to perform usual activities; required medical attention) Swelling, severe pain, bleeding and redness in the arm where the shot was given (rare). A severe allergic reaction could occur after any vaccine (estimated less than 1 in a million doses). What if there is a serious reaction? 5 What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. Afterward, the reaction should be reported to the “Vaccine Adverse Event Reporting System” (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS is only for reporting reactions. They do not give medical advice. 6 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation. 7 How can I learn more? Ask your doctor. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 or visit CDC’s website at www.cdc.gov/vaccines Vaccine Information Statement (Interim) Tdap Vaccine 05/09/2013 42 U.S.C. § 300aa-26 Office Use Only
I have read the above information on the Tdap Vaccine and I decline vaccination at this time.
MMR Vaccine
VACCINE INFORMATION STATEMENT MMR Vaccine What You Need to Know (Measles, Mumps and Rubella) Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis 1 Why get vaccinated? Measles, mumps, and rubella are serious diseases. Before vaccines they were very common, especially among children. Measles Measles virus causes rash, cough, runny nose, eye irritation, and fever. It can lead to ear infection, pneumonia, seizures (jerking and staring), brain damage, and death. Mumps Mumps virus causes fever, headache, muscle pain, loss of appetite, and swollen glands. It can lead to deafness, meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries, and rarely sterility. Rubella (German Measles) Rubella virus causes rash, arthritis (mostly in women), and mild fever. If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects. These diseases spread from person to person through the air. You can easily catch them by being around someone Who should get MMR vaccine and when? 2 Children should get 2 doses of MMR vaccine: First Dose: 12–15 months of age Second Dose: 4–6 years of age (may be given earlier, if at least 28 days after the 1st dose) Some infants younger than 12 months should get a dose of MMR if they are traveling out of the country. (This dose will not count toward their routine series.) Some adults should also get MMR vaccine: Generally, anyone 18 years of age or older who was born after 1956 should get at least one dose of MMR vaccine, unless they can show that they have either been vaccinated or had all three diseases. MMR vaccine may be given at the same time as other vaccines. Children between 1 and 12 years of age can get a “combination” vaccine called MMRV, which contains both MMR and varicella (chickenpox) vaccines. There is a separate Vaccine Information Statement for MMRV. 3 Some people should not get MMR vaccine or should wait. who is already infected. Measles, mumps, and rubella (MMR) vaccine can protect children (and adults) from all three of these diseases. Thanks to successful vaccination programs these diseases are much less common in the U.S. than they used to be. But if we stopped vaccinating they would return. Anyone who has ever had a life-threatening allergic reaction to the antibiotic neomycin, or any other component of MMR vaccine, should not get the vaccine. Tell your doctor if you have any severe allergies. Anyone who had a life-threatening allergic reaction to a previous dose of MMR or MMRV vaccine should not get another dose. Some people who are sick at the time the shot is scheduled may be advised to wait until they recover before getting MMR vaccine. Pregnant women should not get MMR vaccine. Pregnant women who need the vaccine should wait until after giving birth. Women should avoid getting pregnant for 4 weeks after vaccination with MMR vaccine. Tell your doctor if the person getting the vaccine: 5 Has HIV/AIDS, or another disease that affects the immune system What if there is a serious reaction? Is being treated with drugs that affect the immune system, such as steroids Has any kind of cancer Is being treated for cancer with radiation or drugs Has ever had a low platelet count (a blood disorder) Has gotten another vaccine within the past 4 weeks Has recently had a transfusion or received other blood products Any of these might be a reason to not get the vaccine, or delay vaccination until later. 4 What are the risks from MMR vaccine? A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of MMR vaccine causing serious harm, or death, is extremely small. Getting MMR vaccine is much safer than getting measles, mumps or rubella. Most people who get MMR vaccine do not have any serious problems with it. Mild problems Fever (up to 1 person out of 6) Mild rash (about 1 person out of 20) Swelling of glands in the cheeks or neck (about 1 person out of 75) If these problems occur, it is usually within 6-14 days after the shot. They occur less often after the second dose. Moderate problems Seizure (jerking or staring) caused by fever (about 1 out of 3,000 doses) Temporary pain and stiffness in the joints, mostly in teenage or adult women (up to 1 out of 4) Temporary low platelet count, which can cause a bleeding disorder (about 1 out of 30,000 doses) Severe problems (very rare) Serious allergic reaction (less than 1 out of a million doses) Several other severe problems have been reported after What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS is only for reporting reactions. They do not give medical advice. 6 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation. 7 How can I learn more? Ask your doctor. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines a child gets MMR vaccine, including: Deafness Long-term seizures, coma, or lowered consciousness Permanent brain damage These are so rare that it is hard to tell whether they are caused by the vaccine. Vaccine Information Statement (Interim) MMR Vaccine Office Use Only 4/20/2012 42 U.S.C. § 300aa-26
I have read the above information on the MMR Vaccine and I decline vaccination at this time.
Varicella (Chickenpox) Vaccine
VACCINE INFORMATION STATEMENT Varicella (Chickenpox) Vaccine What You Need to Know Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis 1 Why get vaccinated? Chickenpox (also called varicella) is a common childhood disease. It is usually mild, but it can be serious, especially in young infants and adults. It causes a rash, itching, fever, and tiredness. It can lead to severe skin infection, scars, pneumonia, brain damage, or death. The chickenpox virus can be spread from person to person through the air, or by contact with fluid from chickenpox blisters. A person who has had chickenpox can get a painful rash called shingles years later. Before the vaccine, about 11,000 people were hospitalized for chickenpox each year in the United States. Before the vaccine, about 100 people died each year as a result of chickenpox in the United States. Chickenpox vaccine can prevent chickenpox. Most people who get chickenpox vaccine will not get chickenpox. But if someone who has been vaccinated does get chickenpox, it is usually very mild. They will have fewer blisters, are less likely to have a fever, and will recover faster. Who should get chickenpox Catch-up Anyone who is not fully vaccinated, and never had chickenpox, should receive one or two doses of chickenpox vaccine. The timing of these doses depends on the person’s age. Ask your doctor. Chickenpox vaccine may be given at the same time as other vaccines. Note: A “combination” vaccine called MMRV, which contains both chickenpox and MMR vaccines, may be given instead of the two individual vaccines to people 12 years of age and younger. Some people should not get 3 chickenpox vaccine or should wait. People should not get chickenpox vaccine if they have ever had a life-threatening allergic reaction to a previous dose of chickenpox vaccine or to gelatin or the antibiotic neomycin. People who are moderately or severely ill at the time the shot is scheduled should usually wait until they recover before getting chickenpox vaccine. Pregnant women should wait to get chickenpox vaccine until after they have given birth. Women should not get pregnant for 1 month after getting 2 Routine vaccine and when? chickenpox vaccine. Some people should check with their doctor about whether they should get chickenpox vaccine, including Children who have never had chickenpox should get 2 doses of chickenpox vaccine at these ages: 1st Dose: 12–15 months of age 2nd Dose: 4–6 years of age (may be given earlier, if at least 3 months after the 1st dose) People 13 years of age and older (who have never had chickenpox or received chickenpox vaccine) should get two doses at least 28 days apart. anyone who: Has HIV/AIDS or another disease that affects the immune system Is being treated with drugs that affect the immune system, such as steroids, for 2 weeks or longer Has any kind of cancer Is getting cancer treatment with radiation or drugs People who recently had a transfusion or were given other blood products should ask their doctor when they may get chickenpox vaccine. Ask your doctor for more information. 4 What are the risks from chickenpox vaccine? What if there is a serious reaction? 5 A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of chickenpox vaccine causing serious harm, or death, is extremely small. Getting chickenpox vaccine is much safer than getting chickenpox disease. Most people who get chickenpox vaccine do not have any problems with it. Reactions are usually more likely after the first dose than after the second. Mild problems Soreness or swelling where the shot was given (about 1 out of 5 children and up to 1 out of 3 adolescents and adults) Fever (1 person out of 10, or less) Mild rash, up to a month after vaccination (1 person out of 25). It is possible for these people to infect other members of their household, but this is extremely rare. Moderate problems Seizure (jerking or staring) caused by fever (very rare). Severe problems Pneumonia (very rare) Other serious problems, including severe brain reactions and low blood count, have been reported after chickenpox vaccination. These happen so rarely experts cannot tell whether they are caused by the vaccine or not. If they are, it is extremely rare. Note: The first dose of MMRV vaccine has been associated with rash and higher rates of fever than MMR and varicella vaccines given separately. Rash has been reported in about 1 person in 20 and fever in about 1 person in 5. Seizures caused by a fever are also reported more often after MMRV. These usually occur 5–12 days after the first dose. What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. What should I do? If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. VAERS is only for reporting reactions. They do not give medical advice. 6 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate people who may have been injured by certain vaccines. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation. 7 How can I learn more? Ask your doctor. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines Vaccine Information Statement (Interim) Varicella Vaccine 3/13/2008 42 U.S.C. § 300aa-26 Office Use Only
I have read the above information on the Varicella (Chickenpox) Vaccine and I decline vaccination at this time.
I decline to receive the above check marked immunizations at this time. I have been informed of the danger of exposure should I participate in a hands-on experience without immunization protection.

**IMPORTANT NOTICE**
If there is an outbreak and you do not have proper immunizations, you will not be able to continue your experience at Aultman until the outbreak has subsided.

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