<%@ Page Language="vb" EnableViewState="true" EnableSessionState="true" CodeBehind="loadForm.vb" Inherits="eSignProcess.loadForm"%> Measles Immunity Waiver Form for Faculty and Staff

Measles Immunity Waiver Form
Faculty and Staff Only

  

If you are a student, please fill out the Student Measles Waiver Form
 

 Human Resources Department, MS 9054, 516 High Street, Bellingham, WA 98225-5996 (360) 650-3774 FAX: (360) 650-2810     

Request for a WAIVER from the MEASLES IMMUNITY Requirement
   Name:       Western ID#
   Date of Birth:       Current Phone:
 
In support of this request, please answer the following question on the back  or on a separate sheet of paper:
 
   1) State the reason for your request (personal, medical or religious).
   2) Explain the rationale for your reason.
   3) If you are unable to provide a Health Care Provider's signature (see below) in support
     of this request, please explain why.
   4) State whether you believe you have ever received a measles (rubeola or MMR)
  immunization in the past or not.
   5) Explain, in detail, why you are unwilling to get a rubeola titer (blood test for immunity)
  at this time.
 
I understand that immunity to measles (rubeola) is a condition of working at WWU if I was born  in 1957 or later. I understand that it is recommended that I receive the vaccine or prove immunity with a positive rubeola titer (blood test for antibodies).  If my request for a waiver is approved, I understand that if I am exposed to measles, I may be prohibited from campus from the 5th through the 21st day after exposure or for 7 days after the rash appears.  I have been given an opportunity to ask questions about the vaccine, the titer and the policy concerning it.  All my questions have been answered to my satisfaction.  Due to medical, religious or personal reasons, I choose not to demonstrate adequate rubeola immunity.
       
Employee Signature:

   Date:

       
Health Care Provider Documentation (required for medical request):
I certify that this employee has legitimate medical reasons for inadequate rubeola immunity because (state reason):
   
Health Care Provider's Signature/Title/Date Print Name and Title
 
Address (office stamp Okay):

Telephone

     
   

Return completed form to Human Resources Department, MS-9054, 516 High Street
Bellingham, WA 98225-5596 or FAX: (360) 650-2810
 
  Approval by Director of Medical Services, WWU Student Health Center:
  Date: