Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 7, grp. 16, art. 109 app C1
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.
| ___________________________ | ___________________________ |
| Employee Signature | Date |
Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 7, grp. 16, art. 109 app C1