Influenza Vaccination Declination Form - Westport Hall Brooke College printable pdf download

DECLINATION FORM

INFLUENZA VACCINATION

St. Vincent’s Health Services and the CDC have recommended that I receive influenza vaccination in order to protect myself and the

patients to whom I provide care or service.

I acknowledge that I am aware of the following facts:



Influenza is a serious respiratory disease that kills an average of 36,000 people and hospitalizes more than 200,000 people

in the United States each year.



Influenza vaccination is recommended for me and all other healthcare workers to prevent the spread of influenza and its

complication, including pneumonia and death.



If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms appear. By shedding the virus, I can

spread influenza infection and severe illness to others.



The strains of virus that cause influenza change every year, which is why a different influenza vaccine is recommended each

year.



I cannot get the influenza disease from the influenza vaccine because the influenza vaccine does not contain live virus.



Any previous vaccination I received for influenza provides immunity for one season and that annual vaccination is therefore

necessary for ongoing protection.



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 our healthcare settings, my coworkers, my family, my community.



If I contract influenza, I understand I will be required to stay home for 7 days or 2 days after cessation of symptoms,

whichever is greater.



Despite these facts, I am choosing to decline the influenza vaccine because: (please check reason below)

___ A. I have a medical contraindication to receiving flu vaccine: prior history of severe reaction to flu vaccine or history of

Guillian-Barre Syndrome within 6 weeks of taking a flu shot

____B. I’m afraid of needles

___ C. Fear of side effects / Fear of getting sick from the vaccine

___D. other________________________________________________________ (please specify reason)

___ E. If you received it elsewhere (describe where and date received**) ____________________________________

**Documentation from the provider is now required to be brought to the Employee Health Office on Level 1M at the

(or fax to (203) 576-5928)

Medical Center

I understand that I may change my mind at any time and accept influenza vaccination, if vaccine is available. If I choose to

decline the flu vaccination I understand that I will be required to wear a surgical mask, beginning on Dec. 1

and for the

duration of the flu season, at any time that I am providing care or service within 6 feet of a patient. I have read and fully

understand the information on this declination form.

Signature: ____________________________________________

Date: ________________________

Name (print): __________________________________________

Badge #______________________

SVMC

Special Needs

Westport

Hall Brooke

College MSG

Licensed Practitioner Volunteer

Student

(please circle one)

2014-15

Influenza Vaccination Declination Form - Westport Hall Brooke College

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