Influenza Vaccination Request For Exemption Form (Page 2 of 2) in pdf

Influenza Vaccination Request For Exemption Form Page 2

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Masks may be removed during meal and break times to allow the associate to eat and

drink without hindrance.

•

To be fully functional the mask must fit snugly, cover the nose and mouth and be

secured to the face with ties or elastic. The metal nasal piece should be molded securely

to the nose.

•

The mask should be discarded, at a minimum, at the end of the shift and immediately

replaced if it becomes soiled or moist. It is recommended that the mask be changed

approximately every 2 hours or more frequently if needed. A damp mask may

contribute to facial irritation.

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Associates in clinical areas need to continue to follow appropriate Infection Control

guidelines for isolation practices.

Please notify your provider if you develop signs and symptoms of influenza or experience

mask problems.

Despite these facts, I am requesting an exemption from the mandatory influenza vaccine for

the following reasons.

Medical (return form to Chief Medical Officer, AHC Administration)

Guillain-Barre Syndrome

Documented allergy to chicken eggs

Other: _______________________________________________________________

_________________________________________________________________________________

Religious belief or creed (return form to Human Resources Director) ____________________

_________________________________________________________________________________

Please attach additional documentation to this form to further explain the justification for your

request.

I have read and fully understand the information on this form.

Signature: _____________________________________

Date_____________________

Name (print): __________________________________

Department: _____________

Influenza Vaccination Request For Exemption Form Page 2