Attachment 33 Foreign Travel Vacination Review.pdf

Foreign Travel Vaccination Review

Immunization Completion for Travel Out of Country

The following person, _________________________________ has been evaluated for foreign travel to ___________________________________________________ on __________________________.

Signature

Created: 12 July 2011

Statement of Declination of Foreign Travel Immunizations

I, _______________________, understand that the following immunizations, screenings, and/or medications have been recommended by the U.S. Center for Disease Control and Prevention (CDC) for my travel to

_______________. I understand that they are intended to reduce, but not necessarily to eliminate, the risks of my contracting disease while visiting that host country. However, after considering the risks and/or health benefits of said immunizations/screenings, and/or medications for myself and the public, I hereby decline to be vaccinated, to take recommended medications or to have recommended screenings. I fully understand that failure to be immunized may result in disease and/or detention by international public officials until such time that I am authorized to continue my travels.

(Check all immunizations that you are choosing to decline.)

Recommended Vaccination Declined Hepatitis A Hepatitis B Meningococcal Japanese Encephalitis Varicella (Chicken Pox) Measles, Mumps, and Rubella (MMR) Influenza (incl. H1N1) Malaria Pills Polio Booster Tetanus, Diphtheria, and Pertussis (TDAP) Typhoid Fever Yellow Fever PPD Test (Tuberculosis) Other_____________

Name (please print): ___________________________________________________________________________

Signature : __________________________________________________________________________________

Date: ______________________________

Witness (Please print): _________________________________________________________________________

Signature: ___________________________________________________________________________________