Vaccine Refusal and Risk Acknowledgement | Center for Forensic Science

NORTHERN MICHIGAN UNIVERSITY CENTER FOR FORENSIC SCIENCE

Vaccine Refusal and Risk Acknowledgement Form

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The Center for Forensic Science at NMU requires documentation of the following immunizations/tests prior to handling human remains:

Hepatitis B vaccine (complete series)
- Employees and Interns: Titer or signed declination to demonstrate immunity
Up-to-date Tetanus (Td or Tdap) vaccination
- Within the last 10 years
Tuberculosis (TB) screening within the past 12 months
- Repeated annually

This form is to be completed ONLY by individuals who are refusing one or more of the required immunizations or screenings.

VACCINES/SCREENINGS REFUSED

Check all that apply:

Hepatitis B

Vaccination

Titer

Both

Tetanus

(Td/Tdap)

Vaccination (if never received)

Booster (if out of date)

Tuberculosis Test

(PPD, QuantiFERON Gold)

Initial

Annual screening

ACKNOWLEDGMENT OF INFORMATION AND RISK

I understand that:

These immunizations and screenings are recommended based on potential occupational exposure to infectious agents through contact with blood, tissue, and human remains.
Refusing vaccination or testing increases my risk of infection or disease transmission.
I may be restricted from participating in specific lab activities or fieldwork based on refusal.
My refusal of one or more vaccines or tests (identified above) does not exempt me from practicing universal precautions and complying with safety protocols.

I have received information regarding the risks associated with these diseases and the benefits of immunization/testing. I have had the opportunity to ask questions, which have been answered to my satisfaction.

RELEASE OF LIABILITY

By signing this form, I voluntarily decline one or more of the required immunizations or screenings and accept full responsibility for my decision. I release the Center for Forensic Science, Northern Michigan University, its employees, and board members from any liability in the event I contract or transmit a preventable disease.

SIGNATURE

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