Declination Of Influenza Vaccination Form - Immunization Action Coalition printable pdf download

Declination Of Influenza Vaccination Form - Immunization Action Coalition

Declination of Influenza Vaccination

My employer or affiliated health facility, ___________________________, has recommended

that I receive influenza vaccination in order to protect the patients I serve.

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospi-

talizes more than 200,000 persons in the United States each year.

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

influenza disease and its complications, including death.

• If I contract influenza, I will shed the virus for 24–48 hours before influenza symptoms

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

• If I become infected with influenza, even when my symptoms are mild, 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 cannot get the influenza disease from the influenza vaccine.

• The consequences of my refusing to be vaccinated could endanger my health and the health

of those with whom I have contact, including

• patients in this healthcare setting

• my coworkers

• my family

• my community

Despite these facts, I am choosing to decline influenza vaccination right now.

I understand that I may change my mind at any time and accept influenza vaccination, if

vaccine is available.

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

Signature: ____________________________________________ Date: ___________________

Name (print): _________________________________________

Department: __________________________________________

• Item #P4068 (8/06)

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • •

Declination Of Influenza Vaccination Form - Immunization Action Coalition