Influenza Vaccination Declination Form

I,   First Name*   Last Name*   declare that: 

• I understand that I must comply with the infection prevention and control (IP&C) policy at each healthcare facility I attend, as it relates to the requirement for direct contact healthcare workers to be vaccinated against influenza (flu) each year.
• I have read the NSW Health Influenza fact sheet and NSW Health Influenza vaccination information for healthcare workers and I am aware of the potential risks to myself and/or others as a result of declining the influenza vaccine (flu vaccine).
• I decline to receive the influenza vaccine this year.
• I am aware that during the influenza season (1 June to 30 September inclusive), I must wear a surgical mask as a minimum and comply with the (IP&C) infection prevention and control risk reduction strategies at each facility I work in.
• I am aware of the risks and consequences of exposure, including:
  • Viral infection, caused by influenza A or B strains, mainly affecting the lungs, but can affect the heart or other body systems, and can lead to pneumonia and/or heart failure.
  • Spread is via respiratory droplets or through touch transfer. 
  • Spread is most prevalent in confined and crowded spaces.
  • Infectious period is from the day before symptoms start, and up to 5 days for adults and 10 days for children (longer with a weak immune system).
  • Annual vaccination reduces the risk of infection.
  • Young children are at high risk of infection unless vaccinated.
  • More information: NSW Health Influenza fact sheet
• I am aware that failure to comply with uPaged's Influenza Declination policy constitutes a breach in my employment agreement.
• I am aware that I can change my mind at any time and receive a flu vaccine. 
• I have read and fully understand the information on this declination form.

This form is valid for the current flu season. A repeat form will be required for each flu season you decline to be vaccinated for.