TDap Declination Form

Name(Required)

I acknowledge that I am aware of the following facts:

  • Whooping cough (pertussis) is a highly contagious respiratory tract infection.
  • I understand that, due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring an infection with pertussis. By declining the Tdap vaccine, I continue to be at risk of acquiring a serious disease.
Signature(Required)