Declinaon of Inuenza Vaccinaon
My employer or aliated health facility, , recommends that
I receive inuenza vaccinaon to protect myself, paents, sta, and others in the healthcare facility.
I acknowledge that I am aware of the following facts (please read and check each box):
Inuenza is a serious respiratory disease. Each year in the United States, inuenza kills thousands
of
people and causes hundreds of thousands of hospitalizaons.
Inuenza vaccinaon is recommended for me and all other healthcare personnel to protect our
sta and our facility’s paents from inuenza, its complicaons, and death.
If I contract inuenza, I can shed the virus for 24 hours before any inuenza symptoms appear.
During the me I shed the virus, I can transmit inuenza to paents and sta in this facility.
If I become infected with inuenza, even if my symptoms are mild or non-existent, I can spread
inuenza to others. Symptoms that are mild or non-existent in me can cause serious illness and
death in others.
I understand that the strains of virus that cause inuenza infecon change almost every year
and, even if they don’t change, my immunity declines over me. This is why vaccinaon against
inuenza is recommended every year.
I understand that it is impossible to get inuenza from inuenza vaccine.
The consequences of my refusal to be vaccinated could have life-threatening consequences for
my health and the health of everyone with whom I have contact, including my coworkers and all
paents in this healthcare facility.
Despite these facts, I am choosing to decline inuenza vaccinaon for the following reasons:
I understand that I can change my mind at any me and accept inuenza vaccinaon.
I have read and fully understand the informaon on this declinaon form.
Signature Date
Name (print)
Department
refer e n c e: CDC. Prevenon and Control of Seasonal Inuenza with Vaccines: Recommendaons of
the Advisory Commiee on Immunizaon Pracces — United States, . . . Access links to current ACIP
recommendaons at www.cdc.gov/vaccines/hcp/acip-recs/vacc-specic/u.html
FOR PROFESSIONALS www.immunize.org / FOR THE PUBLIC www.vaccineinformation.org
www.immunize.org/catg.d/p4068.pdf
Item #P4068 (8/31/2023)
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