Employee Name Job Title Due to my occupation, I may transmit influenza to patients and other health care workers, as well as, to my friends and family, even though I have no symptoms. This can result in a serious infection, particularly in a person at high risk for influenza complications. My employer has offered the influenza vaccine at no charge. However, I decline the vaccination at this time. If I want to be immunized with influenza vaccination in the future, I can receive the vaccination, at no charge.I am declining the influenza vaccination for the following reason(s). Check all that apply. I've already received the flu vaccination this season. Location you received vaccination I plan to get the vaccine elsewhere. My physician has advised me not to be vaccinated. I do not believe the vaccine will prevent me from getting the flu. I am afraid of injections. Other Explain if you've checked "Other" Employee Name Date MM slash DD slash YYYY
