Vaccine refusal form

Confidential declaration


By completing this form, you are acknowledging the following:


- I understand that, by not having the recommended immunisation schedule associated with my role, I may be at risk of contracting vaccine-preventable diseases

- I understand that, by not having the immunisation schedule associated with my role

- I can spread these vaccine-preventable diseases to other vulnerable children and adults

- The reason for the immunisations associated with my role

Name(Required)
Please select which of the following vaccine you're refusing(Required)
Declaration
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