HomeMy WebLinkAboutEMS-22 - Vaccination Declination FormEMS-22
TB TEST AND VACCINATION TITER BLOOD DRAW
DECLINATION FORM
NAME: Date
Employee ID:
PURPOSE
As part of the Fresno Fire Department’s ongoing commitment to the health and safety of
all personnel, routine Tuberculosis (TB) testing and vaccination titer blood draws are
recommended and, in some cases, required. This form documents your voluntary
decision to decline one or more of these health screenings.
I DECLINE THE FOLLOWING (CHECK ALL THAT APPLY):
☐ Tuberculosis (TB) Test (e.g., PPD, QuantiFERON)
☐ Vaccination Titer Blood Draw(s) for the following:
☐ Measles (Rubeola)
☐ Mumps
☐ Rubella
☐ Varicella (Chickenpox)
☐ Hepatitis B
☐ Other: ___________________________
ACKNOWLEDGMENT AND RELEASE OF RESPONSIBILITY
I acknowledge that I have been informed of the importance of TB testing and vaccination
titer screening as part of occupational health and public safety practices. I understand the
risks associated with declining these screenings, including potential exposure to or
transmission of communicable diseases during the performance of my duties.
By signing this form, I release the Fresno Fire Department, the City of Fresno, and their
officers, agents, and affiliates from any liability or consequences resulting from my
decision to decline these health screenings.
Employee Signature Date
FFD Witness Name (Print)
Witness Signature Date
* This form is intended for record-keeping purposes and will be maintained as part of personnel
documentation.