Declination of Influenza Vaccine

I have read and understand the information provided and explained to me about the influenza Vaccine. I understand that due to my employment or volunteering services, I may be at risk of acquiring the virus. I have been given the opportunity to be vaccinated.

However, I decline vaccination at this time. I understand that by this vaccine, I continue to be at a greater risk of acquiring the influenza virus.
Name*
First Last
Date*
MM slash DD slash YYYY
Reason for Declining Flu Vaccination*
- I think the Flu vaccine will give me the flu
- I have a fear of needles
- I do not think the Flu vaccine works
- I have never had the Flu and do not believe I will get it
- It is against my religious preferences
- I am allergic to the flu vaccine or products used in the vaccine
- I have already been vaccinated for the Flu during this Flu season
- I choose not to disclose my reasoning
(Please select one)
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