2015 Influenza Letter Template For Providers
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12015 Influenza Letter for Providers
Dear Health Sciences Student,
Students in Health Sciences schools/programs are required to be vaccinated against influenza, per the
guidelines set forth by the Centers for Disease Control and Prevention (CDC) for health care personnel.
Many of the area hospitals and clinics expect students assigned there for clinical/practicum placements to
show proof of having received an annual immunization for flu.
HSIP is requesting documentation from students who received their vaccination from outside providers.
We already have your documentation if you went to an HSIP on-site clinic, UWMC Employee Health
Clinic, or HMC Employee Health Clinic.
This form allows your provider to document either administration of influenza vaccine, or
rationale for medical contraindication. Please have your health care provider (MD, ARNP, PA, DO,
or ND only) complete section 1 OR 2, AND 3. A note on letterhead or chart print-out can be
submitted to document flu vaccine administration, but this form MUST be submitted for flu waiver
requests.
Section 1:
Student Name: ___________________________________________________ DOB: ____/____/_____
Last,
First
MO
DAY
YR
Date influenza vaccine received: Month: _________ Day: ________ Year: _________
Type of Vaccine: Injected/Inactivated: ___ or Live/Intranasal: ___ or Recombinant: ___
OR
Section 2:
WAIVERS: If you have a MEDICAL reason for not being able to receive flu vaccine then your provider
(MD, ARNP, PA, DO, or ND) must complete both this section and section 3 below.
PLEASE NOTE: Egg
allergy is no longer a contraindication for most adults. Egg-free vaccine is available.
Student Name: ___________________________________________________ DOB: ____/____/_____
Last,
First
MO
DAY
YR
I have verified that the above named individual has the following medical contraindication, per stated
CDC guidelines referenced at , for
declining influenza vaccination this year: (check applicable box)
□
Severe allergic reaction (e.g. anaphylaxis) after a previous dose of flu vaccine or to a vaccine
component
□
History of Guillain-Barre Syndrome (GBS) within 6 weeks of previous influenza vaccination;
risks of vaccination outweigh benefits at this time
AND
Section 3:
Required:
Signature: _____________________________________________ (MD, ARNP, PA, DO, ND)
Printed Name: _________________________________________
Phone number: _____________________________ Date: ______________________
_____________________________________________________________________
Return this completed form,
signed and dated by
provider, to HSIP, Box 354410, Seattle, WA
98195-4410. Fax to: 206-616-8434 or Email scanned copy to: myshots@uw.edu
Phone: 206-616-9074 for more information
Updated 10/13/15
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