Influenza Declination Form

Influenza Declination Form
Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Department
Position
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I have been offered the seasonal influenza vaccination for the current year and have chosen to decline for the following reason(s):
Other
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.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: