Seasonal Influenza Form

Please complete the Seasonal Influenza Form.

Influenza is a serious respiratory disease that kills thousands of people in the United States each year Influenza vaccination is recommended for all healthcare workers to protect patients from influenza, it's complications and death. If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients. If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non-existent. I understand that strains of the virus that cause influenza infection change almost every year and, even if they don't change, my immunity declines over time. This is why vaccination against influenza is recommended each year. I understand that I cannot get influenza from the influenza vaccine. The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including; my coworkers, family and my community.
I have been advised to be vaccinated with influenza vaccine. If I accept said vaccine, it will be provided at no cost to me by MAS Medical Staffing.*
- I received the influenza vaccine offered by MAS Medical Staffing
- I received the influenza vaccine at another location
- I refuse the influenza vaccine and have signed the declination form below
Name*
First Last
Date*
MM slash DD slash YYYY
Influenza Declination
Please complete the following form if you are declining the influenza vaccination.
I am refusing the influenza vaccine for the following reason:*
In accordance with section 5.4 of the Rules and Regulations Pertaining to Immunization, Testing, and Health Screening for Health Care Workers [R23-17-HCW], a health care worker may refuse the annual seasonal influenza vaccination requirement provided that he or she provides annual written notice of such refusal prior to December 15 of each year to the health care facility in or at which he or she is employed or volunteering, or with which he or she has an employment contract by signing the statement below:
- I have a medical exemption
- I do not think the vaccine works
- I think the vaccine makes me sick
- I do not want to put anything unnatural in my body
- I do not think I am at risk for getting the flu or I do not think my patients are at risk of getting the flu from me
Name*
First Last
Date*
MM slash DD slash YYYY
"I refuse to obtain the annual seasonal influenza vaccination. I understand that, by refusing such vaccination, it is my professional licensing obligation to wear a surgical face mask during each direct patient contact in the performance of my professional duties at any health care facility during any declared period in which flu is widespread. I understand that the consequence for failing to do so shall result in a one hundred dollar {$100} fine for each violation. Failing to do so may also result in a complaint of Unprofessional Conduct being presented to the licensing board that has authority over my professional license. I understand that such licensing complaint, if proven, may result in a sanction such as reprimand, or suspension or revocation of my professional license."*
I agree to the seasonal influenza policy

Please complete the Seasonal Influenza Form.

Influenza Declination