I DO NOT WANT A FLU SHOT.

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease; on average, 36,000 Americans die every year from influenza-related causes.
• Influenza virus may be shed for up to 24 hours before symptoms begin, increasing the risk of transmission to others.
• Some people with influenza have no symptoms, increasing the risk of transmission to others.
• Influenza virus changes often, making annual vaccination necessary. In California, influenza usually begins circulating in early January and continues through February or March.     
• I understand that the influenza vaccine cannot transmit influenza and it does not prevent all disease.
• I have declined to receive the influenza vaccine for this flu season. I acknowledge that influenza vaccination is recommended by the Centers for Disease Control and Prevention for all healthcare workers in order to prevent infection from and transmission of influenza and its complications, including death, to patients, my coworkers, my family, and my community.  

 

Knowing these facts, I choose to decline vaccination at this time. I understand since I am declining the flu vaccination I am required to wear a facemask at all times when on work site. I may change my mind and accept vaccination later, if vaccine is available. I have read and fully understand the information on this declination form.