2021 INFLUENZA VACCINE WAIVER/DECLINATION
Influenza vaccine is STRONGLY RECOMMENDED FOR HEALTHCARE WORKERS, not only to protect themselves,
but to reduce the chance of spreading influenza to our patients and community. Influenza infection can lead
to serious complications and can be fatal, especially in elderly or sick persons, including those who are
hospitalized. When infection occurs despite vaccination, it is usually milder.
1. Have you had a severe (life threatening) allergic reaction to any component of the
vaccine including egg protein or to a previous dose of any influenza vaccination?
2. Do you have a history of allergy to eggs? If yes, please consult with your
physician before receiving the vaccine.
3. Do you have a history of Guillain-Barre syndrome (a severe paralytic illness, also
called GBS) that has occurred within 6 weeks of receipt of a prior influenza
vaccine? If yes, please consult with your physician before receiving the vaccine.
IF YOU HAVE ANSWERED YES TO ANY QUESTIONS LISTED ABOVE, PROCEED TO WAIVER OF VACCINE SECTION.
Complete if not eligible to receive vaccine
I am not eligible to receive the influenza vaccine today based on reason(s) marked above. I understand
that I will be required to wear a surgical mask within six feet of a patient when engaged in patient care or
having contact with patients while performing assigned duties for the duration of the respiratory virus
season, which is generally October through March.
Signature :____________________________ Date:___________________
I am eligible to receive the influenza vaccine, BUT DO NOT WANT to take it. I understand that by refusing
the vaccine I may be putting my SELF, FAMILY, and PATIENTS at risk of getting influenza. I am aware that
hospitalized patients are at increased risk of getting serious complications following influenza infection.
I am declining receipt of flu vaccine based on reasons of conscience, including religious beliefs. I
understand that I will be required to wear a surgical mask within six feet of a patient when engaged in
patient care or having contact with patients while performing assigned duties for the duration of the
respiratory virus season, which is generally October through March.
Name: ___________________
Signature :__________________________ Date:___________________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
