Influenza Vaccination Request For Exemption Form


Agnesian HealthCare
Influenza Vaccination
Request for Exemption Form
I understand that Agnesian HealthCare requires all healthcare workers (HCW) as defined in
policy HR2661 (Influenza Vaccination; Mandatory) to be vaccinated against influenza on an
annual basis, unless granted an exemption. The following form is used to request such an
I acknowledge that I have read and understand the following facts:
Influenza is a serious respiratory disease that kills an average of 36,000 persons and
hospitalizes more than 200,000 persons in the United States each year.
Influenza vaccination is recommended for me and all other HCWs to protect our
patients from influenza disease, its complications and death.
I am likely to be exposed to the influenza virus through the community and bring the
illness into the hospital setting.
If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms
appear. My shedding the virus can spread the influenza disease to patients in this
facility, to my colleagues and family.
If I become infected with influenza, even when my symptoms are mild or non-existent, I
can spread severe illness to others.
I understand that the strains of virus that cause influenza infection change almost every
year, which is why a different influenza vaccine is recommended each year.
I understand that I cannot get influenza from the influenza vaccine.
The consequences of my not being vaccinated could have life-threating consequences to
my health and the health of those with whom I have contact, including,
o Patients utilizing our services
o My co-workers
o My family
o My community
I understand that not being vaccinated as a result of an exemption will require me to
wear respiratory protection at all times during the flu season as defined in policy
HR2661, Influenza Vaccination; Mandatory.
Masking requirements for unvaccinated HCWs during the Flu Season
All HCW who have not been vaccinated against influenza, even if not vaccinated due to
granting of an exception for medical or religious reasons, will be required to wear respiratory
protection, in the form of a mask, while influenza is active in the community. The mask needs to
be worn at all times, with the exception of breaks and meals.


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