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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