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
st
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
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Student
(please circle one)
2014-15