ࡱ> 463M  bjbj== " WW l,,,8d p,2EEE$ !x;E#"EEE; {P EX8 E  |I @)!8:,qIf0`"% `"I Influenza Vaccination Declination Form (Individual) (CONFIDENTIAL) Do not place in health care worker personnel file or disclose outside of the Employee Health Department/Unit Below is a sample declination form to be signed by the health care worker and filed in the health care workers confidential Employee Medical Record. For workplace confidentiality, declinations and other medical information should not be placed in workers personnel files or disclosed outside of the Employee Health Department. I have been offered the influenza vaccination by . I understand that because I work in a health care environment I may place others at risk patients and co-workers if I work while infected with the influenza virus. I have received, and understand, information given to me about the risks and benefits of the vaccine. In declining an influenza vaccination for non-medical reasons, I am aware that: The vaccine does not cause influenza illness. I can be infected by the influenza virus but not feel ill and pass the virus to vulnerable patients who are at-risk of complications or death for influenza. I can also pass the virus to my family, friends and co-workers. Influenza strains change every year and an immunization received in prior years does not usually provide immunity to this years strain of influenza. The vaccine takes about two weeks to reach maximum protection. Therefore, I will not be fully protected from catching the flu until that time. Reasons I do not wish to be vaccinated against influenza: (Circle all that apply.)I do not believe in vaccines for religious or philosophical reasonsI am concerned about side effects and / or safetyI believe the influenza vaccine gives a person the flu.I dont believe the vaccine prevents the flu Its not important I never get the fluIts inconvenientI received influenza vaccine elsewhere (provide documentation)I dont like needles9. I have a medical contraindication. Please check one 9a. ( Allergy to eggs 9b. ( Severe allergy to other vaccine component 9c. ( Guillain-Barre Syndrome Other, please tell us: ( Employee ( MD ( Contractor ( Volunteer Health Care Worker Name (Print) Type of Employee: Check one / / / Health Care Worker Signature Date Signed Employee ID Number Date of Birth If I change my mind, I can receive a free influenza vaccination at Employee Health Services so long as the vaccine is available.     #GH 5 / 0 d e f q r w x $ jUCJOJQJ^JaJCJOJQJ^J j5\6 56>*56j56CJUmHnHu&6EZ[Q  5 $If & F hh^h] 5 6 z {   A B T U LX & F hh($1$If^hd$$Ifl t0644 lal + K L c tfVf`L ($Ifh($1$If^hh($If^h h($Ifd$$Ifl t0644 lal & F hh($1$If^hc d # $ uhaa__   !]  !&d P   &d P d$$Ifl t0644 lal   1h/ =!"##$% i8@8 NormalCJ_HaJmH sH tH <A@< Default Paragraph Font,, Header  !, , Footer  !>B@> Body Text$a$B*CJ$aJ$phH"H Bullet & F(<1$7$8$H$ CJOJQJ   6EZ[Q56z{ABTU+KLcd# $ 00000000000 0 0 0 00000 00 00 00 00 00 00 00 0000000000000000  5 c  8@2(    h WfjJ?DraftImpactB S  ? t"L(t 0:rv 3333 (.Gdd  AdministratorwC:\Documents and Settings\administrator\Local Settings\Temporary Internet Files\OLK33\Declination form BRILL 8-1-07.doc Administrator$C:\Declination form BRILL 8-1-07.doc [K:\COE\wberger\COALITON\NAIAWTOOLKIT_FINAL_07\Declination form BRILL 8-1-07_Salminen_07.docwbergeriK:\COE\Staff Folders\wberger\COALITON\NAIAWTOOLKIT_FINAL_07\Declination form_Individual_revJackson_08.doc?ql}~ e.z+db/ZSrlVQTm6yƢh^`OJQJo(hHh^`OJQJo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJo(hHohPP^P`OJQJo(hH ^`hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`.^`o(.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH88^8`CJOJQJ^Jo(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.8 ^`hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.ZS/rlm6ye.?qI         '                2q                 56z{ABTUKLcd @B @@UnknownGz Times New Roman5Symbol3& z Arial;Wingdings?5 z Courier New"1h&A FA F e 0!#0d  2qHPName_____________________P732772wbergerOh+'0 $ @ L X dpxName_____________________0ameP732772732732Normalwberger8erMicrosoft Word 9.0_@d@.@@.e՜.+,0 hp  Kaiser Permanente_  Name_____________________ Title  !"$%&'()*,-./0125Root Entry F@)!871Table`"WordDocument" SummaryInformation(#DocumentSummaryInformation8+CompObjjObjectPool@)!8@)!8  FMicrosoft Word Document MSWordDocWord.Document.89q