Declinaon of Inuenza Vaccinaon

My employer or aliated health facility, , recommends that

I receive inuenza vaccinaon to protect myself, paents, sta, and others in the healthcare facility.

I acknowledge that I am aware of the following facts (please read and check each box):

Inuenza is a serious respiratory disease. Each year in the United States, inuenza kills thousands

of

people and causes hundreds of thousands of hospitalizaons.

Inuenza vaccinaon is recommended for me and all other healthcare personnel to protect our

inuenza to others. Symptoms that are mild or non-existent in me can cause serious illness and

death in others.

I understand that the strains of virus that cause inuenza infecon change almost every year

and, even if they don’t change, my immunity declines over me. This is why vaccinaon against

inuenza is recommended every year.

I understand that it is impossible to get inuenza from inuenza vaccine.

The consequences of my refusal to be vaccinated could have life-threatening consequences for

Signature Date

Name (print)

Department

refer e n c e: CDC. Prevenon and Control of Seasonal Inuenza with Vaccines: Recommendaons of

the Advisory Commiee on Immunizaon Pracces — United States, . . . Access links to current ACIP

recommendaons at www.cdc.gov/vaccines/hcp/acip-recs/vacc-specic/u.html

FOR PROFESSIONALS www.immunize.org / FOR THE PUBLIC www.vaccineinformation.org