Flu Vaccination Declination Form

Employee Name Job Title Due to my occupation, I may transmit influenza to patients and other health care workers, as well as, to my friends and family, even though I have no symptoms. This can result in a serious infection, particularly in a person at high risk for influenza complications. My employer has offered the influenza vaccine at no charge. However, I decline the vaccination at this time. If I want to be immunized with influenza vaccination in the future, I can receive the vaccination, at no charge. I am declining the influenza vaccination for the following reason(s). Check all that apply. I've already received the flu vaccination this season. Location you received vaccination I plan to get the vaccine elsewhere. My physician has advised me not to be vaccinated. I do not believe the vaccine will prevent me from getting the flu. I am afraid of injections. Other Explain if you've checked "Other" Employee Name Date MM slash DD slash YYYY Submit