California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4 - Division of Industrial Safety
Subchapter 7 - General Industry Safety Orders
Group 16 - Control of Hazardous Substances
Article 109 - Hazardous Substances and Processes
Appendix C1 - Vaccination Declination Statement (Mandatory)

The employer shall ensure that employees who decline to accept a recommended vaccination offered by the employer sign and date the following statement as required by subsection (h)(5)(E):

I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring infection with __________ (name of disease or pathogen). I have been given the opportunity to be vaccinated against this disease or pathogen at no charge to me. However, I decline this vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring __________, a serious disease. If in the future I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination at no charge to me.