UCLA Health Vaccine Declination Form Instructions
This document provides important instructions for volunteers at UCLA Health regarding the Tdap and Hepatitis B vaccine declination. It guides volunteers on how to indicate their vaccination status and seek assistance if needed. Follow these instructions carefully to ensure your safety and compliance while volunteering.
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How do I fill this out?
To fill out this form, read each section carefully and determine your vaccination status. Choose whether you are declining the vaccine or if you have received it, and provide the required information. Make sure to sign and date the form before submission.
How to fill out the UCLA Health Vaccine Declination Form Instructions?
1
Read the instructions for both vaccines.
2
Indicate your current vaccination status.
3
Complete any applicable sections for declining the vaccines.
4
Sign and date the form.
5
Submit the completed form as instructed.
Who needs the UCLA Health Vaccine Declination Form Instructions?
1
Volunteers at UCLA Health who may be exposed to diseases.
2
Individuals who need to declare their vaccination status.
3
Persons declining vaccines for personal reasons.
4
New volunteers needing to complete health documentation.
5
Individuals previously vaccinated wanting to confirm status.
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Click on the edit button to enable editing mode.
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Adjust the text and sections you need to change.
4
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Download your edited PDF once satisfied with the changes.
What are the instructions for submitting this form?
To submit this form, email it to the Volunteer Services Department at volunteer.services@uclahealth.org or fax it to (310) 825-1234. For any in-person submissions, please deliver it to the Volunteer Services office located at 10833 Le Conte Ave., Suite 100, Los Angeles, CA 90095. Ensure that you submit your form before the stated deadlines to avoid any issues.
What are the important dates for this form in 2024 and 2025?
Important dates for the vaccine declination form will include the submission deadlines for volunteer onboarding and annual health compliance reviews, typically occurring at the start of each volunteer program cycle.
What is the purpose of this form?
The purpose of this form is to ensure that all volunteers at UCLA Health understand their vaccination options, particularly concerning Tdap and Hepatitis B. By declaring their vaccination status, volunteers contribute to the overall health and safety of both patients and staff. This voluntary yet crucial document aids in managing potential health risks associated with aerosol transmissible diseases.
Tell me about this form and its components and fields line-by-line.
- 1. Tdap Vaccination Status: Indicates whether the volunteer has received the Tdap vaccine or if they are declining.
- 2. Hepatitis B Vaccination Status: Indicates if the volunteer opts out of the Hepatitis B vaccine or has received it.
- 3. Signature: A signed declaration from the volunteer regarding their vaccination choices.
- 4. Today's Date: The date of form completion.
- 5. Print Name: The printed name of the volunteer.
- 6. Date of Birth: The birth date of the volunteer as identification.
What happens if I fail to submit this form?
Failure to submit this form may result in noncompliance with volunteer health protocols. This can impact your ability to participate in volunteer activities at UCLA Health. Ensure that this form is submitted to avoid any disruptions in your volunteering process.
- Health Compliance Issues: Without submission, you may not meet the health requirements for volunteering.
- Volunteer Status: Noncompliance may affect your eligibility to volunteer.
- Increased Health Risks: Not declaring your vaccination status may expose you and others to potential health risks.
How do I know when to use this form?
- 1. Before Volunteering: Complete the form prior to starting your volunteer work.
- 2. Annual Health Review: Use the form during yearly health evaluations as required by UCLA Health.
- 3. Changes in Health Status: Whenever there are changes affecting your vaccination status, submit the form.
Frequently Asked Questions
How do I fill out the vaccine declination form?
To fill out the form, read through each section, choose your vaccination status, and provide accurate information.
Can I edit the PDF?
Yes, you can edit the PDF using PrintFriendly's editing tools for your convenience.
How do I submit the form?
Follow the submission instructions provided in the form, including email and fax details.
What if I change my mind about declining?
You can resubmit the form at any time should you choose to accept the vaccination in the future.
Is this form mandatory?
Yes, it is a required document for all volunteers working in health-related roles.
Can I download the edited form?
Absolutely! Once you've finished editing, you can download the PDF for your records.
What should I do if I lose my vaccination record?
Contact your healthcare provider for a copy of your vaccination records before filling out the form.
How do I know if I'm eligible for the vaccination?
Consult with your primary care physician regarding your vaccination eligibility and health status.
Does the form require a signature?
Yes, your signature is required to validate your choices regarding vaccination.
Are there any health risks if I decline the vaccination?
Yes, declining may expose you to potential health risks associated with the diseases.
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