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  • Varicella Declination Form

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Disease or pathogen at no charge to me. However, I decline this vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring chickenpox, a serious disease. If in the future I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination at no charge to me. List date(s) of prior varicella vaccination if applicable: Provide documentation to the EHS O.

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How to fill out the Varicella Declination Form online

Filling out the Varicella Declination Form online is a straightforward process that helps ensure that individuals are informed about the risks of varicella zoster virus and their vaccination options. This guide provides step-by-step instructions to assist users in completing the form accurately and effectively.

Follow the steps to fill out the Varicella Declination Form online.

  1. Press the ‘Get Form’ button to access the form and open it in the online system.
  2. Read the introductory information carefully, including the risks associated with varicella zoster virus and vaccination recommendations. This section provides vital context for your decision-making.
  3. Indicate your decision regarding the varicella vaccine by selecting one of the provided options: either to participate in the vaccination program or to decline it.
  4. If applicable, list the dates of any prior varicella vaccinations in the designated section.
  5. Enter your personal information. This includes your full name, phone number, UCSD employee ID number, email address, department name, and department recharge index number for tracking.
  6. Specify the principal investigator you work for, if necessary, along with your participant status by checking all applicable categories provided.
  7. Provide your signature to confirm the accuracy of the information provided and the decision regarding the vaccine. Also, include the date of signing.
  8. Once you have filled in all required fields, save your changes. You can choose to download, print, or share the completed form as needed.

Complete the Varicella Declination Form online today to ensure your health and safety regarding varicella vaccination options.

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Precautions for Varicella Vaccination People with acute severe illness, including untreated, active tuberculosis, should postpone vaccination until they recover. The decision to delay vaccination depends on the severity of symptoms and the etiology of disease.

The chickenpox vaccine is given as an intramuscular injection (injected into the muscle either in your thigh or upper arm). It is usually given as 1 dose, but 2 doses may be recommended for some people. The chickenpox vaccine can be administered with some other vaccines, including MMR, at different injection sites.

Response to vaccines recommended by the subcutaneous route is unlikely to be affected if the vaccines are administered by the intramuscular rather than subcutaneous route. Repeating doses of vaccine administered by the intramuscular route when recommended to be by the subcutaneous route is not necessary (10).

Dosage and Administration 2 doses (0.5 ml each) of varicella vaccine should be given subcutaneously, separated by at least 3 months.

Evidence of immunity includes any of the following: Documentation of two doses of varicella vaccine. Laboratory evidence of immunity or laboratory confirmation of disease; or. Documentation of a diagnosis or verified history of varicella (chickenpox) or zoster (shingles) from a health care provider.

How is the chickenpox vaccine given? The vaccine is given as 2 separate injections, usually into the upper arm, 4 to 8 weeks apart.

(NHJB-2123-P) Form use. This form is used if the person who is named in the will to serve as the executor of an estate or trustee of a testamentary trust does not wish to serve. A declination may not be filed if there are no estate assets.

Those without evidence of immunity should receive 2 doses of varicella vaccine 4 to 8 weeks apart or, if previously received 1 dose, the second dose at least 4 weeks after the first dose.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232