Declination of Influenza Vaccine For more information about the Influenza Vaccine click on the link below. CDC Flu Vaccination Sheet 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* Reason for Declining Flu Vaccination*I think the Flu vaccine will give me the fluI have a fear of needlesI do not think the Flu vaccine worksI have never had the Flu and do not believe I will get itIt is against my religious preferencesI am allergic to the flu vaccine or products used in the vaccineI have already been vaccinated for the Flu during this Flu seasonI choose not to disclose my reasoning(Please select one)PhoneThis field is for validation purposes and should be left unchanged.