Instructions: Complete each section and submit the completed form along with any accompanying vaccination records to Employee Health Services.

Part I: Vaccination Applicability
Vaccination	Applicability	Received through Employee Health Services	Received from an outside source	Declined
Complete Review (Part II)	Complete Declination (Part II)
Vaccinia	Recommended N/A
Yellow Fever	Recommended N/A
Measles, Mumps, Rubella (MMR)	Recommended N/A
Chicken Pox	Recommended N/A
Tetanus Diphtheria Toxoid	Recommended N/A
Meningococcal	Recommended N/A
Seasonal Influenza	Recommended N/A
Other:	Recommended N/A
Part II: Vaccination Review or Declination
Vaccine Review I understand that due to my occupational exposure, I may be at risk of acquiring an infection and may require vaccination as marked in Part I:
Employee Name Printed	Employee ID #
Employee Signature	Date
Vaccine is Declined I understand that due to my occupational exposure, I may be at risk of acquiring an infection. I have been given the opportunity to be vaccinated with the appropriate vaccine(s) at no cost to me. However, I decline the recommended vaccination(s) at this time (as marked in the above table). I understand that by declining this vaccine(s), I continue to be at risk of acquiring a disease. If in the future I continue to have occupational exposure & want to be vaccinated with appropriate vaccine(s), I can receive the appropriate vaccine(s) at no charge to me.
Employee Name Printed	Employee ID #
Employee Signature	Date
Part III: Form Submission
Completed Non-Hepatitis B – Immunization Review and Declination Forms will be filed in medical records. Submit your form to Employee Health Services by either:
or Hand Delivery: Emory University Hospital - 2nd floor, D219 Emory University Hospital Midtown - WW Orr 6th floor	Fax: 404-686-1527

Provide proof of vaccination, e.g., location, date.

Yerkes employees contact the Safety Officer at the Yerkes facility.