Pneumococcal Vaccination Acceptance/declination Form printable pdf download

Pneumococcal Vaccination Acceptance/Declination Form

Due to your occupational exposure to Streptococcus pneumoniae you may be at risk of acquiring pneumococcal disease

infection, including pneumonia, bacteremia, and meningitis. You may obtain screening and/or the pneumococcal

vaccination from the Center for Occupational & Environmental Medicine (COEM) at no cost to you.

The pneumococcal vaccination is offered (voluntary) to all individuals working with S. pneumoniae. However,

it is highly recommended for those who may be at risk of complications due to certain personal health

conditions:

1) immune compromise (e.g., HIV infection, leukemia, lymphoma, Hodgkins disease, cancer, chemotherapy, chronic

kidney disease, organ transplant, long-term systemic steroid use).

2) chronic diseases (e.g., asthma, diabetes, chronic respiratory or cardiac disease, liver disease, alcoholism)

3) smokers

4) age 65 years or older

Pneumococcal pneumonia vaccination may not be recommended if you have documentation of prior vaccination or if

medical evaluation identifies that vaccination is contraindicated.

The pneumococcal vaccination may be obtained from the UCSD Center for Occupational & Environmental Medicine

(COEM) at no cost to you. Contact the EHS Occupational Health Nurse for an authorization form if you are requesting

vaccination (858-534-8225).

Please review the Vaccine Information Statement (attached, see page 2-3) or available at:

, then choose one of the following options:

I certify that I have been offered and request to receive the pneumococcal vaccination and/or screening (as

medically indicated). I understand that I must request an appointment for these medical services by contacting

UCSD Center for Occupational and Environmental Medicine (COEM).

I understand that due to my occupational exposure to Streptococcus pneumoniae, I may be at risk of acquiring

pneumococcal disease infection. I have been given the opportunity to receive the pneumococcal vaccination and/or

screening (as medically indicated), at no charge to myself. However, I decline vaccination at this time. I

understand that by declining this vaccine, I continue to be at risk of acquiring pneumococcal disease. If in the

future I continue to have occupational exposure and I want to be vaccinated, I can receive the vaccination at no

charge to me.

If you have received prior pneumococcal immunization, list date: ____________. Provide documentation to the EHS Occupational Health

Nurse at Fax# 858-534-7561 or mail code 0091. For questions, call 858-534-8225.

Employee Name (print)__________________________________________ Phone#: _______________

UCSD Employee ID#: ________________________ Email address _____________________________

Dept Name:._______________________________ Dept Recharge Index#: ______________________

(required for tracking purposes only)

Principal Investigator you work for__________________________________

Participant Status (check all that apply):

[ ]

Faculty

[ ]

Staff

[ ]

Visiting Scientist

[ ]

Affiliate

[ ]

UCSD Registered Volunteer

[ ]

Non-registered Volunteer

[ ]

UCSD-Paid Undergraduate Student

[ ]

Non-Paid Undergraduate Student

[ ]

UCSD-Paid Graduate Student

[ ]

Non-Paid Graduate Student

[ ]

Non-Senate Academic Staff

[ ]

Other

(specify if UCSD-paid assignment or not):

________________________________________

________________________

Signature of Employee

Date signed

Return to: EH&S Occupational Health Nurse, Mail Code 0091

I:Bio_SafetyFORMSVaccine formsForms in Word versionPneumococcal-VaccineAcceptDecline-2014.doc

Updated 5/8/2014

Pneumococcal Vaccination Acceptance/declination Form

Related Articles

Related forms

Related Categories