Influenza declination form

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DATE: Sept. 21, 2017, 7:58 a.m.

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  36. INFLUENZA VACCINATION WRITTEN DECLINATION FORM Influenza is a serious respiratory disease; on average, 36,000 Americans die every year from
  37. Infect Control Hosp Epidemiol. 2008 Apr;29(4):302-8. doi: 10.1086/529586. Use of a mandatory declination form in a program for influenza vaccination of
  38. Declination of Influenza Vaccination. For Health Care Personnel. Employee's Name: Employee's ID#:. I have been advised that I should receive the influenza
  39. 20 Mar 2015 The declination form program was compatible, flexible, easy to use, and supported by leadership. • Declination form program facilitators
  40. Influenza Vaccine Declination. 2011-2012. Written declination is required by new California law (SB 739) beginning in 2007. I acknowledge that I am aware of
  41. Influenza Vaccination Consent or Declination Form. I understand it is my responsibility to obtain the influenza vaccine if required at clients I am scheduling at
  42. Adapted from the California Department of Public Health Declination Form published 2012. 2016-2017 INFLUENZA VACCINATION WRITTEN DECLINATION
  43. that I receive influenza vaccination to protect the patients I serve. I have read and fully understand the information on this declination form. Signature:
  44. Influenza Vaccination Attestation/Declination Form. Healthcare facilities are recommending that all healthcare workers and students be vaccinated annually with
  45. I have read the “Influenza Vaccine Information Statement”. I have had an I have read and fully understand the information on this declination form. Print name
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