California Code of Regulations (Last Updated: August 6, 2014) |
Title 8. Industrial Relations |
Division 1. Department of Industrial Relations |
Chapter 4. Division of Industrial Safety |
Subchapter 7. General Industry Safety Orders |
Group 16. Control of Hazardous Substances |
Article 109. Hazardous Substances and Processes |
Aerosol Transmissible Diseases |
Appendix c1. - Vaccination Declination Statement (Mandatory) |
The employer shall ensure that employees who decline to accept a recommended vaccination offered by the employer sign and date the following statement as required by subsection (h)(5)(E): I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring infection with ________________ (name of disease or pathogen). I have been given the opportunity to be vaccinated against this 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 _____________________, 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.
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