VHA Directive 1192.01, Seasonal Influenza Prevention Program for VHA Health Care Personnel.pdf

August 10, 2020

B-1

VHA DIRECTIVE 1192.01

APPENDIX B

HEALTH CARE PERSONNEL INFLUENZA VACCINATION FORM

I am a VA: ___ Employee ___ Volunteer ___ Other (e.g. Trainee, Resident, Intern, Fee Basis, or Researcher) Please indicate: __________________________

CHECK ONE STATEMENT BELOW AND COMPLETE AND SIGN THE LAST SECTION OF

THIS FORM PRIOR TO SUBMISSION TO EMPLOYEE OCCUPATIONAL HEALTH:

I received the seasonal influenza vaccine this flu season (any required documentation is attached).

I have been granted a medical exemption from receiving the seasonal influenza vaccine this flu season. I have a contraindication for flu vaccine as defined by CDC. The reasons for contraindication must be recognized contraindications and precautions by the Centers for Disease Control and Prevention, found here: https://www.cdc.gov/flu/prevent/whoshouldvax.htm.

This has been discussed and acknowledged by my personal physician. I understand that by declining to receive the vaccine by November 30 or within two weeks of beginning employment, I must wear a face mask according to requirements and guidelines within VHA Directive 1192.01, Seasonal Influenza Vaccination Program for VHA Health Care Personnel.

Printed Physician Name and Address Physician Signature

Supervisor Signature Date

Supervisor Email

I notified my immediate supervisor in writing that I have a deeply held religious belief that prevents me from receiving the seasonal influenza vaccine this influenza season. I understand that by declining to receive the vaccine by November 30 or within two weeks of beginning employment, I must wear a face mask according to requirements and guidelines within VHA Directive 1192.01, Seasonal Influenza Vaccination Program for VHA Health Care Personnel.

Supervisor Signature Date Supervisor Email

I have read and fully understand the information on this form and have been given the opportunity to have my questions answered. I understand that violation of the directive may result in disciplinary action up to and including removal from federal service.

Name (print): _________________________ Last 4 SS# _______ Dept./Serv: ____________________

Employee Signature: ______________________________ Date: ______________

Date National Provider Identification Number

Employees and volunteers provide this form to the VHA facility Employee Occupational Health Office. Health Professions Trainees provide this form to the Designated

Education Officer. Secure electronic submission is permissible.

VISN Employee