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Varicella History/Declination, attest that, to the best of my (PRINTED Employee Name)knowledge, I have had Chicken Pox (or Shingles): YES NO Don't know understand if I answered No or Don't Know to

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How to fill out varicella historydeclination

01

Gather all the necessary information about the person for whom the varicella historydeclination is being filled out.

02

Start by providing the personal details of the individual, such as their name, date of birth, and contact information.

03

Indicate the person's medical history and any relevant vaccination records.

04

If the person has previously had varicella (chickenpox) or received the varicella vaccine, specify the dates and details.

05

If the person has declined the varicella vaccine, provide an explanation for the declination.

06

Include any additional information or comments that may be relevant to the varicella historydeclination form.

07

Review the filled-out form for accuracy and completeness before submitting it.

08

Submit the varicella historydeclination form to the appropriate entity or healthcare provider as required.

Who needs varicella historydeclination?

01

Individuals who have had varicella (chickenpox) in the past and can provide documentation of their illness.

02

Individuals who have received the varicella vaccine and can provide proof of vaccination.

03

Individuals who have chosen not to receive the varicella vaccine and need to formally decline it.

04

Parents or legal guardians filling out the varicella historydeclination form on behalf of their children.

05

Schools, colleges, and healthcare facilities that require documentation of varicella history or declination.

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