Flu Vaccination Declination Form

  • 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.

  • MM slash DD slash YYYY