The following notice is designed to inform your employer of the conditions under which you will comply with their flu shot (or other vaccine) request. See Notice http://legal-dictionary.thefreedictionary.com/Notice
Before filling out and turning in this notice, employees must request the vaccine package insert for the vaccine they are being asked to take. If this insert is provided, inform the employer that you must take it home to read and consider. DO NOT JUST READ IT AND HAND IT BACK. It could be used as evidence should you accept the vaccine and get injured by it.
If no insert is provided, fill out and deliver the Vaccine Notice (a). If it is provided use the Vaccination Notice (b).
This Vaccination Notice was designed as a tool to help employees decline unreasonable flu shot (or other vaccine) requests . . . and hopefully keep their jobs.
Vaccination Notice for Employees (PDF) with instructions
Employee-Student Vaccination Notices a and b.doc
Vaccination Notice for Employees-Students template 6-30-14.doc
All Vaccination Notices Listed Here
VACCINATION NOTICE (a)
Notice to agent is
notice to principal
Notice to principal is
notice to agent
As
an employee
or student of
XYZ
MEDICAL CENTER, INC,
I declare the following:
My
employee
or school is
requesting that I accept a flu
shot vaccine as a
condition of my employment
or attendance.
1)
I am aware that those manufacturing, ordering and/or administering
vaccines have been granted immunity from liability should I suffer
from a vaccine caused injury or illness, such as Guillian Barre. The
Vaccine Injury Compensation Trust Fund is not an acceptable
alternative to me. (Reason listed below - #7)
2)
Enclosing the adverse effects of pharmaceutical products is common
practice for pharmacists. So, unless I am provided the vaccine
manufacturer's package inserts, I will not have been given the
information I need to make an informed decision regarding the risks
of taking the vaccine. CDC, public health, or other vaccine
information sheets and/or websites are not acceptable alternatives.
(Reason listed below - #4).
3)
I am aware that vaccine recommendations have been established by the
CDC and are promoted by public health departments and other
organizations.
4)
I do not recognize the CDC as a government health advocacy
organization. It is a corporation listed on Dun and Bradstreet and
headquartered in the STATE OF GEORGIA, with strong ties to the
pharmaceutical industry. Therefore, their recommendations are
influenced by the 'fiscal' health of their own corporation.
5)
I do not recognize the HEALTH,
OHIO DEPARTMENT OF
as a government health advocacy organization. It is listed on Dun and
Bradstreet, is headquartered in COLUMBUS
OH, has strong
ties to the pharmaceutical industry and receives monetary
compensation to promote vaccines. Therefore, the state public health
department's recommendations and actions are influenced by the
'fiscal' health of their own corporation.
6)
I am aware of multiple scientific peer-reviewed papers, such as "Thevaccination policy and the Code of Practice of the Joint Committee on Vaccination and Immunisation (JCVI): are they at odds?"
which have provided proof that governments have been concealing the
dangers of many vaccines as well as the truth about the "herd
immunity myth" of 1933.
7)
I am aware that the corporation HEALTH & HUMAN SERVICES, UNITED
STATES DEPARTMENT OF (listed on Dun and Bradstreet and headquartered
in WASHINGTON DC) determines claims paid from the Vaccine Injury
Compensation Trust Fund via a secret administrative hearing that
lacks due process and also profits by owning vaccine patents.
8)
I am unaware of any state statute that grants XYZ
MEDICAL CENTER, INC
the authority to require employees
or students to
take a pharmaceutical product - that is not warranted as either safe
or effective by the manufacturer - as a condition of their employment
or admission. If such a statute exists, please send me the name,
number and effective date.
For
the reasons I have listed and more, I cannot comply with XYX
MEDICAL CENTER, INC'S
vaccine request unless I am provided with the vaccine package insert,
allowed to determine if the health risks are acceptable, and receive
a document stating that XYX
MEDICAL CENTER, INC
(not the Vaccine Injury Compensation Trust Fund) agrees to be
financially responsible for any and all injuries, illnesses (as
defined by the International Medical Council on Vaccination) or
losses this vaccine might cause me.
NOTE:
Please place this notice in my employee records file.
Employee:
Jane
Doe Address: 2425
Maple Lane, Grove City, Ohio
Signature: Jane
Doe Date: 5-15-14
Witness: John
Walton Date: 5-15-14
Witness: Roy
Rogers Date: 5-15-14
-------------------------------------------------------------------------------------------
VACCINATION
NOTICE (b)
Notice to agent is
notice to principal
Notice to principal is
notice to agent
As
an employee
or student of
XYZ
MEDICAL CENTER, INC,
I declare the following:
My
employee
or school is
requesting that I accept a flu
shot vaccine as a
condition of my employment
or attendance.
1)
I am aware that those manufacturing, ordering and/or administering
vaccines have been granted immunity from liability should I suffer
from a vaccine caused injury or illness, such as Guillian Barre. The
Vaccine Injury Compensation Trust Fund is not an acceptable
alternative to me. (Reason listed below - #7)
2)
I requested, received and reviewed the manufacturer's package insert
for the vaccine I am being requested to take.
3)
I am aware that vaccine recommendations have been established by the
CDC and are promoted by state public health departments and other
organizations.
4)
I do not recognize the CDC as a government health advocacy
organization. It is a corporation listed on Dun and Bradstreet and
headquartered in the STATE OF GEORGIA, with strong ties to the
pharmaceutical industry. Therefore, their recommendations are
influenced by the 'fiscal' health of their own corporation.
5)
I do not recognize the HEALTH,
OHIO DEPARTMENT OF
as a government health advocacy organization. It is listed on Dun and
Bradstreet, is headquartered in COLUMBUS
OH, has strong
ties to the pharmaceutical industry and receives monetary
compensation to promote vaccines. Therefore, the state public health
department's recommendations and actions are influenced by the
'fiscal' health of their own corporation.
6)
I am aware of multiple scientific peer-reviewed papers, such as "Thevaccination policy and the Code of Practice of the Joint Committee on Vaccination and Immunisation (JCVI): are they at odds?"
which have provided proof that governments have been concealing the
dangers of many vaccines as well as the truth about the "herd
immunity myth" of 1933.
7)
I am aware that the corporation HEALTH & HUMAN SERVICES, UNITED
STATES DEPARTMENT OF (listed on Dun and Bradstreet and headquartered
in WASHINGTON DC) determines claims paid from the Vaccine Injury
Compensation Trust Fund via a secret administrative hearing that
lacks due process and also profits by owning vaccine patents.
8)
I am unaware of any state statute that grants XYZ
MEDICAL CENTER, INC
the authority to require employees
or students to
take a pharmaceutical product - that is not warranted as either safe
or effective by the manufacturer - as a condition of their employment
or admission. If such a statute exists, please send me the name,
number and effective date.
For
the reasons I have listed and more, I cannot comply with XYX
MEDICAL CENTER, INC'S
vaccine request unless XYX
MEDICAL CENTER, INC
provides me with a signed document stating that XYX
MEDICAL CENTER, INC
(not the Vaccine Injury Compensation Trust Fund) agrees to be
financially responsible for any and all injuries, illnesses (as
defined by the International Medical Council on Vaccination) or
losses this vaccine might cause me.
NOTE:
Please place this notice in my employee records file.
Employee:
Jane
Doe Address: 2425
Maple Lane, Grove City, Ohio
Signature: Jane
Doe Date: 5-15-14
Witness: John
Walton Date: 5-15-14
Witness: Roy
Rogers Date: 5-15-14
PARENTS AGAINST MANDATORY VACCINES
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