Declination of MMR
.docx
School
Des Moines Area Community College**We aren't endorsed by this school
Course
NURSING 123
Subject
Medicine
Date
Jan 9, 2025
Pages
1
Uploaded by JusticeFreedomDugong29
Declination of MMR (Measles, Mumps, & Rubella) VaccinationIt is has recommended I contact my primary care provider to receive my MMR vaccine to protect myself, the patients I serve, my colleagues, and others I may be in contact with during my essential duties. I acknowledge that I am aware of the following facts: MEASLES (M) causes fever, cough, runny nose, and red, watery eyes, commonly followed by a rash that covers the whole body. It can lead to seizures (often associated with fever), ear infections, diarrhea, and pneumonia. Rarely, measles can cause brain damage or death.MUMPS (M) causes fever, headache, muscle aches, tiredness, loss of appetite, and swollen and tender salivary glands under the ears. It can lead to deafness, swelling of the brain and/or spinal cord covering, painful swelling of the testicles or ovaries, and, very rarely, death.RUBELLA (R) causes fever, sore throat, rash, headache, and eye irritation. It can cause arthritis in up to half of teenage and adult women. If a person gets rubella while they are pregnant, they could have a miscarriage or the baby could be born with serious birth defects.Most people who are vaccinated with MMR will be protected for life. Vaccines and high rates of vaccination have made these diseases much less common in the United States.The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact with including but not limited to:omy patients and other patients in this healthcare settingocoworkersofamilyocommunity membersIf you are exposed to mumps and are not immune, you can spread the disease three days before you have symptoms. If you get mumps, you will be off work for five days or until the symptoms disappear, whichever is longer. I understand I can change my mind at any time and receive the MMR vaccination if the vaccine is available. I have read the vaccine information sheet attached to this form. I have had an opportunity to ask questions and understand the benefits and risks of the MMR vaccination. I do not wish to receive the vaccine at this time and request that it not be given to me or to the person named below, for whom I am the parent or guardian. I have read and fully understand the information on this sheet. ___________________________________________________Name of person declining vaccine (please print)Date_______________________________________________Signature of person declining vaccine or parent or guardian_____________________Department
