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. Immunity following vaccination is strongest for 2 to 6 months. 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 the 2020-2021 season. I acknowledge that the 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.
- NurseRegistry clients will be notified that I declined.
I decline vaccination for the following reason(s Please check all that apply.
1.I am declining the influenza immunization for one of the justified reasons. Please check all that apply and provide details on the bottom of the page.
____Severe allergies to eggs, vaccine components, or prior influenza vaccines. Describe your reaction:___________________________________________
____History of Guillain-Barre Syndrome. Did you see your doctor after receiving the flu shot?
____Declaration of another medical contraindication.
____My philosophical or religious beliefs prohibit vaccination.
2. I do not wish to take the vaccine for the following reasons - Please check all that apply.
____I don't believe this vaccine is important. I don't like needles.
____I never get the flu.
____I have had a reaction to flu shots: (Check below) Local pain, redness, swelling Body aches, low fever
____Got the flu after receiving the shot Had to see a doctor
Knowing these facts, I choose to decline vaccination at this time. I have read and fully understand the information on this declination form.