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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 1, Chapter 12:  Manual Appendix IX

Refusal Form

I have been provided information about the following infectious diseases and vaccines:

_______________________ Measles and rubella and measles and rubella vaccines

I read the information and any questions I had about these diseases and vaccines were satisfactorily discussed with me.

Furthermore, I read and understand the Indian Health Service (IHS) Employee Immunization Policy.

My immunization status has been reviewed and evaluated by an appropriate IHS health professional, and based on that review, evaluation and the policy of the IHS, I understand that I am unprotected against the following diseases:

_______________________ Rubella
_______________________ Measles

However, I do not consent to receive vaccine(s) to the above listed disease (s) I initialed.  The potential risks of being unprotected against these/this disease(s) was explained to me.  I understand that I am subject to be reassigned or removed from the Service because of my refusal.

Date:_______________________________________
Witness:____________________________________ Employee:_________________________________________


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