Influenza Vaccination Medical Exemption Request printable pdf download

Influenza Vaccination Medical Exemption Request

Applicant: Please make a copy of this completed form and any supporting documents for your

own records and send the original to:

Hartford Hospital Occupational Health

80 Seymour Street, PO Box 5037

Hartford, CT 06102-5037 OR FAX: 860-545-2137

Request for Medical Exemption from Universal Influenza Vaccination

Request #________

Safety is a core value of Hartford HealthCare. To protect the safety of our patients, coworkers, and

community, Hartford HealthCare requires all employed and non-employed staff members to receive a flu

shot by November 1.

If you believe that you have a medical reason that prevents you from receiving the influenza vaccine, you

must submit this completed form by October 1 of the year in which you wish to be excused from receiving

the vaccine. The exemption form will be reviewed by a team of healthcare professionals. Hartford

HealthCare reserves the right to confirm the information provided with your healthcare provider. By signing

this form, you hereby authorize Hartford HealthCare health professionals to contact your medical provider

regarding conditions that prevent you from receiving the influenza vaccination. If your request is approved,

you will be medically exempted from receiving influenza vaccine and you will be required to wear a mask

while at any Hartford HealthCare location when you are within 6 feet of a patient/client during influenza

season. If your request is not approved, you will be expected to receive the influenza vaccine.

Staff Member Signature____________________________________________Date____________

Staff Member completes this section:

Staff Member’s Last Name (print below)

Staff Member’s First Name (print below)

Street Address (print below)

City/ State/Zip Code (print below)

Date of Birth:

Telephone number:

Employee ID number:

Department:

Division of Hartford HealthCare:

Medical Provider completes this section:

Describe the specific medical reason that precludes the above staff member from receiving

influenza vaccine. Please attach any supporting documentation clearly marked with the staff

member’s name and date of birth.

Provider’s Last Name (print below)

Provider’s First Name (print below)

Street Address (print below)

City/ State/Zip Code (print below)

Telephone:

Fax:

Healthcare Provider’s Signature_______________________________ Date__________________

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Influenza Vaccination Medical Exemption Request