AGENCY STAFF* FLU VACCINATION DECLINATION

AGENCY STAFF* FLU VACCINATION DECLINATION
*Agency Staff are those individuals who report to work at a facility pursuant to an agreement between Client and the Individual’s employer.

I ACKNOWLEDGE THAT I AM AWARE OF THE FOLLOWING FACTS (Please read):

I understand that I may be a risk for acquiring influenza and transmitting the virus to others. I have been given the opportunity to be vaccinated with the inactivated influenza vaccine; however, I decline the influenza vaccination at this
time. I understand that by declining this vaccine, I continue to be at risk for acquiring influenza, a serious illness and of transmitting the virus to others. I understand that I can change my mind at a later time and accept vaccination if the vaccine is still available. As required by the Center, I will wear a mask at all times (with the exception of the employee lounge/break room) at the Center. The mask will be supplied by the location at no cost to me.

I DECLINE THE INFLUENZA VACCINE FOR THE FOLLOWING REASON(S) (CHECK ALL THAT APPLY):*

Registrant’s Name (PRINT)*

First NameLast Name

Registrant’s Signature *

Date*

Date