Fillable DECLINATION WAIVER FOR THE INFLUENZA VACCINE Please complete (Wayne State University)

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DECLINATION WAIVER FOR THE INFLUENZA VACCINE Please complete (Wayne State University)

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DECLINATION WAIVER FOR THE INFLUENZA VACCINE
Please complete this form and send it to your HR Consultant and to the Campus Health Center.
Name:_________________________________
School/College/Division:__________________
AccessID:______________________________
Supervisor’s Name:_______________________
Title:__________________________________
Department:____________________________
Phone No:______________________________
Supervisor’s Email Address:_______________
Objection to obtain the influenza vaccine is based on the following reason(s). Please
check all that apply.
____Medical
____Religious
____Moral
____Ethical
By signing this document, I understand that by declining a vaccine, or being a vaccination non-
responder, I continue to be at risk of acquiring an illness.
_____________________________________________ _______________________
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DECLINATION WAIVER FOR THE INFLUENZA VACCINE Please complete (Wayne State University)

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Completed 22 October 2020

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