Declination of Influenza Vaccination Form
This document serves as a formal declination of influenza vaccination for healthcare personnel. It provides essential information about the importance of vaccination and the consequences of refusal. Each employee must read and understand the implications before signing.
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How do I fill this out?
To fill out this form, begin by entering your name and employee ID at the top of the document. Next, read through the information regarding influenza vaccination carefully. Finally, sign and date the form to finalize your declination.
How to fill out the Declination of Influenza Vaccination Form?
1
Enter your personal details including name and employee ID.
2
Read the information provided about influenza vaccination.
3
Understand the implications of declining the vaccine.
4
Sign the declaration statement.
5
Date the form appropriately.
Who needs the Declination of Influenza Vaccination Form?
1
Healthcare employees who are required to get vaccinated.
2
Employees who have medical contraindications to the vaccine.
3
Workers in healthcare settings during flu season.
4
Staff who prefer not to receive the vaccine for personal reasons.
5
New employees in healthcare facilities who need to comply with vaccination policies.
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What are the instructions for submitting this form?
To submit the declination form, first ensure that all required fields are completed and signed. You can send the signed form via email to your designated health compliance officer or submit it in person at your workplace's HR department. Please keep a copy for your records as a confirmation of your declination.
What are the important dates for this form in 2024 and 2025?
For 2024, the influenza vaccination season typically runs from September to April. Employees should submit their declination forms by August 31, 2024. Additionally, the same timeline applies for 2025, with forms due by August 31, 2025, to ensure compliance.
What is the purpose of this form?
The purpose of this form is to document the decision of healthcare personnel to decline the influenza vaccination. It also serves to inform signers about the risks of not being vaccinated and the related health implications. The form ensures that all employees understand their responsibility for protecting themselves and patients during influenza season.
Tell me about this form and its components and fields line-by-line.
- 1. Employee's Name: The name of the employee who is opting to decline the vaccination.
- 2. Employee's ID#: The identification number assigned to the employee.
- 3. Signature: The employee's signature confirming their decision.
- 4. Date: The date when the declination form is signed.
- 5. Witness: The signature of a witness verifying the employee's decision.
- 6. Witness Date: The date when the witness signs the form.
What happens if I fail to submit this form?
Failing to submit this form may lead to consequences regarding employment and compliance with health regulations. Employees who do not submit their declination may be required to receive the vaccination. Additionally, there may be disciplinary actions for non-compliance with health protocols.
- Health Risks: Refusing vaccination increases the risk of influenza spread in the workplace.
- Employment Compliance: Employees may face disciplinary action for not adhering to vaccination policies.
- Patient Safety: Declining the vaccine compromises the health of patients in care.
How do I know when to use this form?
- 1. Declining Vaccination: Use this form when opting out of the influenza vaccination.
- 2. Employee Records: Document your decision for future reference in employee records.
- 3. Health Compliance: Ensure compliance with health department regulations.
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What happens after I submit the form?
Ensure you follow up with your healthcare facility regarding the next steps after submission.
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