Influenza Vaccination Declination Form - Trinity Presbyterian Preschool
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1Trinity Presbyterian Preschool
INFLUENZA VACCINATION DECLINATION FORM
I understand that the California Health & Safety Code section 1596.7995 requires that I
obtain a flu shot
between August 1 and December 1
each year or provide this
declination.
____
I HAVE ELECTED NOT TO HAVE A FLU SHOT
I acknowledge that I am aware of the following facts:
Influenza is a serious respiratory disease; on average, 36,000 Americans die every
•
year from influenza related causes.
Influenza virus is contagious for up to 24 hours before symptoms begin, increasing the
•
risk of transmission to others.
Some people with influenza have no symptoms, increasing the risk of transmission to
•
others.
Influenza virus changes often, making annual vaccination necessary. In California,
•
influenza usually begins circulating in early January and continues through February
or March.
I understand that the influenza vaccine cannot transmit influenza.
•
I understand that the influenza vaccine does not prevent all disease.
•
I acknowledge that influenza vaccination is recommended by the Centers for Disease
Control and Prevention for all early childhood education workers in order to prevent
infection from and transmission of influenza and its complications, including death, to
students, my coworkers, my family, and my community.
Knowing these facts, I choose to decline vaccination for the current flu season.
I have read and fully understand the information on this declination form.
Print Name: ______________________________________________
Signature: ____________________________________
Date: ____________________________
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