PRINT NAME: __________________________________________ DOB: __________________
I acknowledge that I am aware of the following facts:
Influenza is a serious respiratory disease; on average, 34,000 Americans die every year from influenza-
related causes.
Influenza virus may be shed for up to 24 hours before symptoms begin, increasing the risk of
transmission to others.
Some people with influenza have no symptoms, increasing the risk of transmission to others.
Influenza virus changes often, making annual vaccination necessary. Immunity following vaccination is
strongest for 2 to 6 months. In California, influenza usually begins circulating in early December and
continues through March.
I understand that the influenza vaccine cannot transmit influenza and it does not prevent all disease.
Influenza vaccination is recommended by the Centers for Disease Control
Prevention for all healthcare workers in order to prevent infection from and transmission of influenza
and its complications, including death, to patients, my coworkers, my family, and my community.
Prevention of and reduction in the severity of influenza illness and reduction of outpatient visits,
hospitalizations, and intensive care unit admissions through influenza vaccination also could alleviate
stress on the U.S. health care system.
Influenza vaccination is especially important during the SARS-CoV-2 pandemic.
I am choosing to decline flu vaccine for the one of the following reason. Please check all that apply.
Medical Precaution or Contraindication
Religious Belief
Personal Belief
Other Reason __________________________________________
Prefer not to answer
I acknowledge that I am required to follow non-pharmaceutical interventions (e.g. masking, screening) as
directed by Chief Clinical Officer, the local vaccine authority and that my manager, including division and
departmental leadership will be notified of the same.
I acknowledge, if I later decide to become vaccinated, that I may receive the vaccine through UCSF Occupational
Health Services, or off-site and provide documentation to UCSF Occupational Health Services.
I have read and fully understand the information on this declination form. Knowing these facts, I DO NOT want
the vaccination as recommended and choose to decline a vaccination at this time.
Print Name ___________________________ Signature ______________________________ Date___________
Phone Number____________________Department_____________________Manager’s Name__________________
When complete, please scan and email to FLU@ucsf.edu with subject as ‘Flu Shot Declination Form’
or fax to UCSF Occupational Health Services at 415-514-5614
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