When should I use this form?
o This form must be completed before seeking reimbursement for the cost of the
accine. Please note that it does not need to be signed for vaccinations
administered at Parliament House.
What should I do with this form?
o To receive reimbursement for the cost of the vaccine, scan and email a copy of
the signed form and the r
eceipt for the cost of the vaccine to:
nderstand that the cost of the flu vaccine may be reimbursed as part of a
vaccination program for employees who have voluntarily requested
to be vaccinated.
I acknowledge and understand that I do not have to be vaccinated if I do not want
I confirm that I am aware of any potential risks resulting from the vaccine,
• mild local reactions at the injection site, including a lump (induration),
soreness, redness and swelling;
• more common reactions that may include fever (> 37.5°C), headache, chills,
malaise and myalgia; and
• very rarely, severe allergic reaction.
I acknowledge and accept that the Department of Finance has no responsibility in
the event that I suffer any side effect resulting from the workplace vaccination
program for employees.
Signature of employee:
FLU VACCINATION PROGRAM CONSENT FORM