College/Employment Waiver Form - Michigan Opposing Mandatory

OR COLLEGE
VACCINATIONEXEMPTIONFOREMPLOYMENT
VACCIIIEEXEttlPfIOlt FORII
do
the risksandbenefitsof the vaccine(s)
afterconsidering
(insertyourname)
vaccines:
thefollowing
frereby
decidenotto rcceive
- Diphtheria
- Tetanus
- Perfussis
- Polio
-HepatiUsB
- Measls
_ Meningitis
* Mumps
_ Influenza
- Rubella
- Otlrer:
q/peb
- Haemophilus
influenzae
*Varicella
(please
reasn below):
choose
Reason
Religious
Offier
"other ot
Pursuantto my right to refuse vaccinationon the sfiafutorygrounds of
immunization."
meansBtatyou as an indMdualright
TO IMMUNIZATION
OBIECEON
Theterm OROTt-lER
wheilreror not to be vaccinated.As wim any medicaldecision,the decisionb vaccinate
your docbr and publichealthemployesca
rightof flre indMdual,The Shte of Michigan,
you to be vaccinated,Youcannotbe excludedftom a publicschoolor publicptogrambe
yourrightnotto vaccinate.
haveexercised
collegeor univensity.
b myemployer,
I am providing
a copyof the statement
Date:
YourSignaturc
Page1 of 2
Ra4iN uft4
Marf,aturyvrcirw: P.o.tux rtur, 77onMI M*1121
tutrw: MidttganWilg
Vde Matl(ffi) tH7-2418.|HISrctut IAY tr REW@LEED
www.momtMng.otg
Making Infomed Decisions
cancal
or not shouldbe an informeddecision.Vaccines
Yourdecisionto vaccinate
m
which
redions,
minor
braindamageor
injuriesincludingseizures,death,anaphylaxis,
fever. Thetypeandseverityof reactionsmayvaryformwccineto vaccine,Theeffectsof t
injurymaybetemponryor permanent.If younoticeanydrangesin youor yourchild'scon{
or go to a hospital.Novaccineis on
ffre shot,you shouldcontactyourdoctorimmediately
percenteffectiveand you or your child may conhct the diseaseeven if you are vacini
reactionratesand effiectivenssof vaccinesvaryftom vaccineto vaccine.Youmayevenc(
diseasefrom the vaccineif the vaccinecontainsa live viruslike polio. The immunitypro'
periodically
t0 continue
with timeandyou mayneedb be re-vaccinated
vaccinedecreases
yourself
your
vaccines,
somevacc
with
all
awilable
child
or
vaccinate
may
You
chooseto
you
shouldresearch
vary
the risksandbenefitsof eachvaccination
at all. Because
vaccines
are.
risks
benefits
the
and
vaccinewhat
Youshouldprovidea detailedhistoryto the healthproviderof any healthabnormalil
if you or yourchildhashadrcactionsto ''
yourchildmayhavepriorto vaccinating
especially
neurological
conditionor is immunedeficient.Underrertaincon
the past,hasa pre-o<isting
that yourchildnot receivethe vaccir
manufactr.lrer
or healthcareprovidermayrecommend
to beadmini:
Youshouldalsofindout at whatagesthevaccineis recomrnended
vaccination,
Risksof llon-Vacination
If you do not wccinateyourcelfor your child,you or your child may be at a higl
person.Thediseasemayresultin minorsymptomt
frrana vaccinated
the disease
contracting
will vary depend
irrcluding
death. The natureand severityof complications
complications
paniculardisease.Tharisksof contracting
disearesmay\ary overUmeor by lmality. Thed
from the diseasemay be treatableby altemativemt
bme or all of the complicaUons
Becausethe risK from eachdiseasevary I
wittrout
Feafitent.
resoMe
or may
antibioUcs
the diseaseand
with the disease,fte likelihoodof conUacting
researchthe risksassociated
disease,
the
meffiodsof ffeating
For Morc Information
on the
To makean informeddecisionthere are numercussourcs of infurmaUon
to d
infurmation
of
from
Sourcs
risK
involved
ilre
disease.
ffie
vaccine
and
the
benefitsof
package
insert,ph)4
wi$ the vaccineoutweighthe benefitsincludethe
the risksassociated
publicandmedicallibraries,st8t
ConbolandPrevention,
reference,
U.S.Centersfor Disease
your
healthagencietthe Foodand DrugAdminisffiation, healthcare providers,Michigan
VaccineI
andil,teNational
or www.momvaccines.otg
Vaccines
at (586)447-2418
Mandatory
or (703)938-0342or wwnt/.909shot.com.
Centerat (800)909-SHOT
Repofting Reactions
Youshouldrepoftvaccinereactionsto the VaccineAdverseEventRepottingSystem(
(800) 822-7967.If you do chooseto vaccinate,makesure you receivethe nameof tl
manufacturer
andSrelot number.If you or yotlr childhasa rnccineinjury,you or yourch
Vaccine
Injury&mpensationAct.
underthe National
eligiblefor compensation
Page2 of 2
ReuWl Oy14
tutre: Mid?igan
WadrE lrlatffitory VMna: P,0.tux 7721,TronMI 48W-1121
Voieriail (W) 4fl-2418. THISF0nn rUY re RERODLIGD
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