Flu Appendix B 10-9050 Waiver Form.pdf

This is a VA Form 10-9050, Health Care Personnel Influenza Vaccination Form (August 2020 version), used by the Department of Veterans Affairs to document influenza vaccination compliance among healthcare personnel.

The form serves as a declaration document requiring healthcare workers to attest to one of three compliance pathways: receipt of the seasonal influenza vaccine with attached documentation, medical exemption with CDC-recognized contraindication supported by physician documentation, or religious belief exemption. Employees and volunteers must select their employment status category and complete the form prior to submission to Employee Occupational Health. For individuals granted exemptions, the form mandates face mask wearing per VHA Directive 1192.01. The form requires signatures from the healthcare personnel member, physician (if claiming exemption), and supervisor, along with dates and contact information. Employees must acknowledge understanding that violation of the directive may result in disciplinary action up to and including removal from federal service. Completed forms are submitted to the VHA facility Employee Occupational Health Office, with Health Professions Trainees submitting to their Designated Education Officer. Secure electronic submission is permitted.