Acknowledgment of Risks:
I understand that influenza is a serious respiratory illness that can lead to severe complications, hospitalization, and even death. I acknowledge that by declining the influenza vaccine, I may be at an increased risk of contracting and spreading the influenza virus.
Alternative Measures:
I understand that [Organization Name] encourages employees to take alternative measures to prevent the spread of influenza, including regular handwashing, practicing respiratory hygiene, and staying home when sick.
Employee Signature:
By signing below, I acknowledge that I have been offered the influenza vaccine by [Organization Name] and have chosen to decline. I understand the potential risks associated with not receiving the vaccine.