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