Skip to Main Content

This information is provided free of charge by the Department of Industrial Relations from its web site at These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at
Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 109. Hazardous Substances and Processes

Return to index
New query

§5199. Appendix C1.

The employer shall ensure that employees who decline to accept a recommended vaccination offered by the employer sign and date the following statement as required by subsection (h)(5)(E):
I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring infection with ________________ (name of disease or pathogen). I have been given the opportunity to be vaccinated against this disease or pathogen at no charge to me. However, I decline this vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring _____________________, a serious disease. If in the future I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination at no charge to me.
Employee Signature

Go BackGo Back to Article 109 Table of Contents