Influenza Vaccine Declination

2024-2025 INFLUENZA VACCINE DECLINATION FORM

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills thousands in the United States each year.

• Influenza vaccination is recommended for me and all other healthcare personnel to protect this.

• Facility’s patients from influenza, its 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 in this facility.

• 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 the strains of virus that cause influenza infection change almost every year and even if they don’t, 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 all patients in this.

• Healthcare facility, coworkers, my family and my community prevention of and reduction in the severity of influenza illness and reduction of outpatient visits, hospitalizations, and intensive care unit admissions through influenza vaccination also could alleviatestress on the U.S. health care system.

• Influenza vaccination is especially important during the SARS-CoV-2 pandemic.

I am choosing to decline flu vaccine for the one of the following reasons. Please check all that apply.

Medical Precaution or ContraindicationReligious BeliefPersonal BeliefOther ReasonPrefer not to answer

I acknowledge that I am required to follow non-pharmaceutical interventions (e.g. masking, screening) asdirected by Chief Clinical Officer, the local vaccine authority and that my manager, including division and departmental leadership will be notified of the same.

I acknowledge, if I later decide to become vaccinated, that I may receive the vaccine through UCSF OccupationalHealth Services, or off-site and provide documentation to UCSF Occupational Health Services.

I have read and fully understand the information on this declination form. Knowing these facts, I DO NOT want the vaccination as recommended and choose to decline a vaccination at this time.