Flu Declination Form

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
• If I contract influenza, I can shed the virus for 24 hours before symptoms appear, increasing the risk of transmission to others.
• If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread the illness to others, who can become seriously ill.
• Influenza viruses change often and, even if they don’t change, immunity declines over time, making annual vaccination necessary.
• I understand that the influenza vaccine cannot transmit influenza and it does not prevent all disease.
• I understand that due to my occupational exposure to aerosol transmissible diseases, I may be at risk of acquiring seasonal influenza. I have been given the opportunity to be vaccinated against influenza with no charge to me. I further understand that influenza vaccination is recommended by the Centers for Disease Control and Prevention for me and all other healthcare workers to prevent infection from and transmission of influenza and its complications, including death, to patients, my coworkers, my family, and my community. However, I decline vaccination at this time. I understand that by declining this vaccination, I continue to be at increased risk of acquiring influenza, a serious disease. If, during the flu season, for which the Centers for Disease Control and Prevention recommends administration of the influenza vaccine, I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination at no charge to me.
• Because I have declined vaccination for influenza, I have been advised that in order to protect the safety of my patients and myself during this flu season, I may be required by a public health mandate, Kaiser Permanente policy, and/or a collective bargaining agreement to wear a mask when delivering patient care or working in patient care areas. Even if I decline vaccination and am not required by a public health mandate, Kaiser Permanente policy, or a collective bargaining agreement to wear a mask, I understand that refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including patients, my coworkers, my family and my community.

Knowing these facts, I choose to decline vaccination at this time. I may change my mind and accept vaccination later, if vaccine is available. I have read and fully understand the information on this declination form.