Upload Records
Complete this form only if you have new updates to your vaccination record. If you are unsure what is on file with your employer, please review your
vaccination record (only accessible from the health organization networks).
Upload Records
Having technical difficulties uploading files?
I would like to decline vaccinations for the following (optional):
You have chosen to decline the following vaccinations:
Chickenpox
Hepatitis B
Rubella
Mumps
Polio
Tetanus/Diphtheria
Measles
Confirm Declination
By declining to be vaccinated, you understand and agree that you may be excluded from work in the event of a
vaccine-preventable communicable disease exposure or outbreak.
If you decide later that you would like to be vaccinated or you need more information, please contact your organization's Workplace Health team or visit a vaccination clinic.