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COVID-19 VACCINATION DECLINATION FORM

COVID-19 VACCINATION DECLINATION FORM 2025

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The document outlines the COVID-19 vaccination requirement for all employees, medical staff, and volunteers at Pomona Valley Hospital Medical Center (PVHMC), mandating vaccination by September 30, 2021, in accordance with California's public health order. It details the process for requesting exemptions based on qualifying medical reasons or religious beliefs, including necessary forms and submission guidelines. Exemption requests will undergo confidential reviews by designated panels, and unvaccinated associates must adhere to specific testing requirements.

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What is a declination form?

Declination form means the form that is signed by and collected from Clients who decline voter registration services. A Client refusing to sign the Voter Registration Form is also a Declination.

What is the purpose of declination?

Influenza Vaccination Declination Form (Mandatory) Print Name: I DO NOT WANT A FLU SHOT. I acknowledge that I am aware of the following facts: Knowing these facts, I choose to decline vaccination at this time. I may change my mind and receive vaccination later. I decline vaccination for the following reason(s).

How to document vaccine declination?

Give the appropriate Vaccine Information Statement (VIS) to the parent or legal representative before each vaccine is given. This is required by federal law. When parents refuse a recommended vaccine, document that you provided the VIS(s), and have the parent sign the Record of Vaccine Declination.

What is the declination form?

A coverage declination form is a document that agencies should use as part of their workflow process for situations when a client declines coverage. The client signs the form to acknowledge that they reviewed the coverage with their agent and that they are declining to purchase coverage.

What to put on flu declination form?

A hepatitis B declination form is a form your employer may give you to offer you the hepatitis B vaccine option due to the occupational risk of exposure to the virus.

How to get exemption from COVID-19 vaccine in USA?

In order to request a religious exception, please fill out this form. The agency may ask for other information as needed to determine if you are legally entitled to an exception. Signing this form constitutes a declaration that the information you provide is, to the best of your knowledge and ability, true and correct.

COVID-19 VACCINATION DECLINATION FORM 2025

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