Vaccine Declination Form

Piute School District

Vaccine Declination Form

Employee’s Name _____________________________________                 Date: ________________________

School Name: ____________________________

I understand that because I work in an environment with possible exposure to vaccine-preventable illness, I may be at risk of acquiring a vaccine-preventable illness from an unvaccinated student or staff member at school.

However, I decline vaccination at this time. I understand that be declining vaccination, I continue to be at risk of acquiring a vaccine-preventable illness.

In the event of a disease outbreak, I understand that I may be sent home and remain at home as directed by Piute County School District in consultation with the Health Department. I understand that I can take personal leave, vacation leave (if applicable), emergency leave, or leave without pay with prior approval of my administration. I understand that I may not use sick leave.

________________________________________________                        ________________________

Employee’s Signature                                                                                       Date

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Piute County School District
500 North Main - P.O. Box 69
Junction, Utah 84740-0069
Phone: (435)-577-2912 - Fax: (435)-577-2561
© 2020 Piute County School District
Piute School District does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs. Please contact your school principal for further information.