Revised Annual Influenza Vaccination Declination Form

Annual Influenza Vaccination Declination Form

Caring Shepherds Healthcare Inc

Print Name

DOB

I acknowledge that I am aware of the following facts: Influenza is a serious respiratory disease and on average 30,000-60,000 people die every year from influenza related causes. Transmitted through airborne exposure. May be preventable by vaccine. People 65 years and older are at higher risk of developing serious flu complications compared with young, healthy adults. Vaccine is recommended once a year. Caring Shepherds will provide me with more information about getting the vaccine should I decide to get the vaccine.

Knowing these facts, I choose to Decline the vaccination currently. I have read and fully understand the information on this declination form.

Acknowledging these facts, I am choosing to:

I WILL take the Influenza vaccination and will provide theI WILL NOT take the Influenza vaccination this year

Signature

Date

Supervisor Signature