When should I use this form?
o This form must be completed before seeking reimbursement for the cost of the
flu v
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:
I u
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:
Printed Name:
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