Declination of Influenza Vaccine

For more information about the Influenza Vaccine click on the link below.

CDC Flu Vaccination Sheet


  • 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.

    (Please select one)
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