HPV Op Out Form
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Department of Health
Information about Human Papillomavirus and Vaccination and Vaccine Refusal Form for Students at District of Columbia Public, Charter, Private and Parochial Schools Instructions for completing HPV Vaccine Refusal Certificate
Section 1: Enter student information
Section 2: Have parent/guardian or student (if > 18 years of age) initial, sign and date after reading
Vaccine Information Statement (s)
Name of School
Section 1: Student Information
Student Name:
Date of Birth:
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