Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 7, grp. 16, art. 109, app C2

Current through Register 2024 Notice Reg. No. 43, October 25, 2024
Appendix C2 - Seasonal Influenza Vaccination Declination Statement (Mandatory)

The employer shall ensure that employees who decline to accept the seasonal influenza vaccination offered by the employer sign and date the following statement as required by subsection (h)(10):

I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring seasonal influenza. I have been given the opportunity to be vaccinated against this infection 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 increased risk of acquiring influenza. If, during the season for which the CDC recommends administration of the influenza vaccine, 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 SignatureDate

Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 7, grp. 16, art. 109, app C2