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Get Varicella Declination Form

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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