To fill out an immunization declination form correctly, use the official version issued by your employer, school, or state health department; identify the exact vaccine or vaccines you are declining; state the basis (medical, religious, or philosophical) if the form asks for one; attach the right supporting documentation for that basis; and sign and date the form before submitting it through a channel that gives you proof of delivery. The exact fields vary, but the sequence below covers every common version.
First, Figure Out Which Form You Need
Not every declination works the same way. The workplace hepatitis B declination under OSHA’s bloodborne pathogens standard uses fixed, mandatory language and requires no reason.1Occupational Safety and Health Administration. 1910.1030 – Bloodborne Pathogens Almost every other declination form — flu vaccines in healthcare settings, other workplace vaccine policies, and school or childcare immunizations — requires you to state a specific basis for opting out and to back it up with documentation.
Before you write anything, ask the office that gave you the form which version is current and whether they accept it electronically or only on paper. Submitting an outdated form or one downloaded from an unrelated website is one of the most common reasons for immediate rejection.
Filling Out the OSHA Hepatitis B Declination
If your job exposes you to blood or other potentially infectious materials, your employer must offer the hepatitis B vaccine at no cost. If you refuse, OSHA requires you to sign this exact statement, quoted word for word in Appendix A of the standard:2Occupational Safety and Health Administration. Hepatitis B Vaccine Declination (Mandatory)
“I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.”
That statement is the entire form. You read it, sign it, and date it. No religious or medical reason is required. Your employer keeps it on file, and you can change your mind later; if you still have occupational exposure, the employer must provide the vaccine at no cost when you ask for it.3Occupational Safety and Health Administration. Hepatitis B Declination Statement
Filling Out a Declination That Requires a Reason
Most other forms follow a similar layout. Work through it in order.
Personal Identifiers
Fill in your full legal name, date of birth, and the institutional ID number the form asks for — employee ID, student registration number, or medical record number.4University of Minnesota. Declination Form – Tetanus Have these ready before you start; a mismatch between the name on the form and the name in your file can delay review.
The Vaccine or Vaccines You Are Declining
Forms either list vaccines with checkboxes or leave a blank for you to write them in. Name each specific vaccine you are declining. Do not write “all vaccines” if you only object to one — a broader refusal than you intend can create complications with vaccines you would actually accept.5Goucher College. Vaccination Declination Form
The Basis for Declination
Most forms ask you to check a box for medical, religious, or (in some states, for school immunizations) philosophical grounds. Pick one and be sure it matches the documentation you plan to attach.
Medical exemptions rest on a recognized contraindication such as a documented severe allergic reaction to a vaccine component or an immune condition that makes the vaccine dangerous. Under the ADA, your employer should engage with you in a flexible, interactive process to identify a reasonable accommodation.6U.S. Equal Employment Opportunity Commission. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws
Religious exemptions rest on a sincerely held religious belief that conflicts with vaccination. Title VII protects traditional and nontraditional religious beliefs alike, and the belief does not have to come from an organized religion.7U.S. Equal Employment Opportunity Commission. Fact Sheet: Religious Accommodations in the Workplace Objections that are purely social, political, or based on personal views about vaccine safety do not qualify.6U.S. Equal Employment Opportunity Commission. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws
Philosophical exemptions apply only in the 16 states that allow non-medical, non-religious exemptions for school immunizations.8National Conference of State Legislatures. Brief State Non-Medical Exemptions From School Immunization Requirements They are not a recognized basis for workplace exemptions under federal law.
The Risk Acknowledgment
Many forms include a paragraph describing the health risks of remaining unvaccinated and ask you to sign or initial next to it. Read that language carefully. You are confirming that you have been informed of the risk, not agreeing that you should get the vaccine.
Signature and Date
Sign with the same name you used in the identifier section. Date the form on the day you sign it; the date starts any applicable review clock.
Supporting Documents to Attach
What you attach depends on the basis you checked.
Medical exemption. Attach a signed statement from a licensed physician (usually an MD or DO). The statement should identify the specific vaccine or vaccines, the specific medical reason (for example, an allergy to a vaccine component, a documented immune disorder, or a prior adverse reaction), and whether the exemption is temporary or permanent. Include the physician’s name and license number. A vague note saying the patient “should not be vaccinated” without a stated reason is likely to be rejected.9New York City Public Schools. Medical Request for Immunization Exemption Unless the physician specifies a lifelong condition, expect to renew annually.
Religious exemption. Attach a personal written statement explaining what you believe and how that belief conflicts with the specific vaccine you are declining.10Illinois Department of Public Health. Illinois Certificate of Religious Exemption to Required Immunizations and/or Examinations Form You do not need a letter from a clergy member and you do not need to name a religion. Make it specific enough to show the belief is genuinely religious rather than a general discomfort with vaccines, and keep it consistent with anything you have said before on the subject; reviewers can look for contradictions. State requirements for school religious exemptions vary: some require a notarized affidavit, others accept a plain written statement. North Carolina, for example, requires no notarization, no attorney, and no signature from a religious leader — just a written statement for each child that includes the child’s name, date of birth, and the reason for the objection.
Philosophical exemption. Where allowed, documentation is usually simpler: a signed statement or affidavit affirming your personal objection. Some states require notarization. Check your state health department’s page for the specific form.
Submitting the Form
Send the completed form and attachments through the channel the institution specifies. Many employers and schools now use secure online portals for health documents. If you submit on paper, use certified mail with a return receipt or hand-deliver and get a signed acknowledgment from the receiving office. Keep a copy of everything, including the form and each attachment.
Review times vary. One university health sciences program asks applicants to allow 15 business days.11University of Oklahoma Health Sciences College of Dentistry. College of Dentistry Handbook 2025-2026 – Vaccine Declinations Larger institutions may take longer. If the reviewer contacts you for clarification or additional documentation, respond quickly; many policies close an inactive request after a set number of days. You should receive a written determination when the review is finished.
After You Submit
Approval often comes with conditions. In workplaces, the EEOC has noted employers may require alternative safety measures such as wearing a mask, working a modified shift, periodic testing, telework where feasible, or reassignment to a lower-exposure position.6U.S. Equal Employment Opportunity Commission. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws Schools may exclude an unvaccinated student from campus during a disease outbreak.
If your declination is denied, read the letter for the specific reason. If it was denied because of missing or thin documentation, you can often resubmit with a more detailed physician’s letter or a more specific religious statement addressing what the reviewer flagged. If you believe a workplace religious or medical exemption was wrongly denied, you can file a charge with the EEOC. Many employers and schools also have an internal appeal process with deadlines that can be as short as 15 days from the denial, so check the handbook right away.
A signed declination is never permanent. If you later decide to be vaccinated, tell the office holding your form and submit proof of vaccination once you get it; your file is updated to your current status. For the OSHA hepatitis B declination in particular, the employer must provide the vaccine at no cost whenever you request it, as long as you still have occupational exposure.3Occupational Safety and Health Administration. Hepatitis B Declination Statement