Influenza Vaccination Declination Form - CSUSM
This document is the Influenza Vaccination Written Declination Form required by California State University, San Marcos. It outlines the necessary information and facts regarding influenza vaccination. Use this form if you choose not to receive the flu shot for the specified season.
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How do I fill this out?
To fill out this form, start by reviewing the required declarations carefully. Next, provide your printed name, signature, and date to indicate your choices. Finally, submit the completed form to the designated department.
How to fill out the Influenza Vaccination Declination Form - CSUSM?
1
Read the influenza vaccination information thoroughly.
2
Fill in your printed name and sign the form.
3
Date the form when you complete it.
4
Keep a copy for your records.
5
Submit the completed form as instructed.
Who needs the Influenza Vaccination Declination Form - CSUSM?
1
Employees at California State University who opted out of the flu vaccination for the specified year.
2
Students involved in early childhood education programs needing to declare their vaccination choice.
3
Healthcare workers associated with the university that must document their vaccination status.
4
Volunteers participating in university-sponsored children’s programs who are required to submit their vaccine status.
5
Members of any university-related organization requiring proof of vaccination compliance.
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What are the instructions for submitting this form?
Submit the completed Influenza Vaccination Declination Form either via email to health@csusm.edu or fax at (760) 750-3200. You can also submit the form in person at the Health Center located on campus. Ensure you keep a copy for your records after submission.
What are the important dates for this form in 2024 and 2025?
For the 2024 flu season, the vaccination period runs from August 1 through December 1. Individuals must submit their declination form by December 1 to be compliant with university policies. For the 2025 flu season, follow the same timeline for submission.
What is the purpose of this form?
The purpose of the Infl influenza Vaccination Written Declination Form is to formally document the decision of individuals who choose not to receive the influenza vaccine at California State University, San Marcos. This ensures compliance with state regulations regarding health and safety. It plays a critical role in safeguarding public health within the university community by tracking vaccination statuses.
Tell me about this form and its components and fields line-by-line.
- 1. Printed Name: Where the individual should write their full name.
- 2. Signature: Space for the individual to sign their name.
- 3. Date: Field for entering the date of signature.
What happens if I fail to submit this form?
If this form is not submitted, individuals may face consequences such as being non-compliant with university health policies. This can lead to possible restrictions on employment or participation in university activities. It's crucial to submit the declination form to avoid any negative implications.
- Health Risks: Failure to submit may increase the risk of influenza transmission within the university community.
- Employment Status: Non-compliance can affect your current employment or future hiring opportunities.
- Participation Restrictions: You may be barred from participating in university programs or events.
How do I know when to use this form?
- 1. Employment Compliance: Employees must submit this form if they do not receive the flu shot.
- 2. Student Health Requirements: Students in specific programs must acknowledge their vaccination status.
- 3. Program Participation: Participants in university-sponsored events may need to document their flu vaccination decision.
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