DECLINATION WAIVER FOR THE INFLUENZA VACCINE
Please complete this form and send it to your HR Consultant and to the Campus Health Center.
Supervisor’s Email Address:_______________
Objection to obtain the influenza vaccine is based on the following reason(s). Please
check all that apply.
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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