Influenza Declination


My employer or affiliated healthcare facility has recommended that I receive influenza vaccination in order to protect myself and the patients I serve. I acknowledge that I am aware of the following facts:

  • Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.

  • Influenza vaccination is recommended for me and all other healthcare workers to prevent influenza disease and its complications, including death.

  • If I contract influenza, I will shed the virus for 24–48 hours before influenza symptoms appear. My shedding the virus can spread influenza infection to patients in this facility.

  • If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others.

  • I understand that the strains of virus that cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year.

  • I cannot get the influenza disease from the influenza vaccine.

  • The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including: patients in this healthcare setting; my coworkers; my family; and my community.


I have read and fully understand this form. I understand that if I have declined, I may change my mind at any time and accept the influenza vaccination, if the vaccine is available.