Flu Vaccination Statement

I acknowledge that I am aware of the following facts:

  • Influenza is a serious respiratory disease that kills, on average, 36,000 Americans every year.
  • Influenza virus may shed for up to 48 hours before symptoms begin, allowing transmission to others.
  • Up to 30% of people with influenza have no symptoms, allowing transmissions to others.
  • Flu virus changes often, making annual vaccinations necessary. Immunity following vaccination is strongest for 2 to 6 months.
  • I understand that flu vaccine cannot transmit influenza. It does not, however, prevent all disease.
  • I acknowledge that influenza vaccination is recommended by the CDC for all healthcare workers to prevent infection from and transmission of influenza and its complications, including death, to patients, my coworkers, my family, and my community.

Influenza Vaccination Confirmation


I received the influenza vaccine through another source this year.
Date and Location of received influenza vaccination

Influenza Vaccination Declination


Knowing these facts, I choose to decline the vaccination at this time. I may change my mind and accept the vaccination later, at no cost from my employer. I have read and fully understand the information on this declination form.

I have decided to decline the offer of the influenza vaccine at this time for the following reasons (Please check all that apply)

I have a severe allergy to eggs or vaccine component, or have been diagnosed with Guillain-Barre.
I am concerned about potential side effects or safety of the vaccine
My philosophical or religious beliefs prohibit vaccination.
I never get the Flu.
I dislike needles or shots.
I believe I may get the flu if I get the shot.
Other (please describe) :

I acknowledge that I have read this influenza Declination Statement entirely and fully understand it. I know that if I change my mind I can obtain the vaccine at no cost from my employer.