Exemption Or Refusal Of Flu Vaccination Form printable pdf download

Exemption or Refusal of Flu Vaccination Form

My employer or affiliated health facility,

, is requiring that I

receive a flu vaccination.

I acknowledge that I am aware of the following facts:



Influenza is a serious respiratory disease that kills thousands of people in the United States

each year.



Influenza vaccination is recommended for me and all other healthcare workers to protect

this facility’s patients from influenza, its complications, and death.



If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear.

My shedding the virus can spread influenza to patients in this facility.



If I become infected with influenza, even if my symptoms are mild or non-existent, I can

spread it to others and they can become seriously ill.



I understand that the strains of virus that cause influenza infection change almost every year

and, even if they don’t change, my immunity declines over time. This is why vaccination

against influenza is recommended each year.



I understand that I cannot get influenza from the influenza vaccine.

The consequences of my refusing to be vaccinated could have life-threatening consequences to my health

and the health of those with whom I have contact, including



all patients



my coworkers



my family



my community

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:

______________________________________________________________________________________

I understand that I must return this form to my supervisor and the form will be retained by the

Bureau of Human Resources in my personnel file.

Furthermore, by declining the flu vaccination I understand that I will be required to wear a mask beginning

December 1, 2015 through the remainder of the flu season and refusing to wear a mask may lead to

being

placed on furlough and/or subject to further disciplinary

action.

I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still

available.

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

Signature: ____________________________________Date:

___________________________

Name (print): _________________________________ Department:

_______________________

Program Manager: _________________________________ Date:

_______________________

Exemption Or Refusal Of Flu Vaccination Form

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