D.9- HEALTH CARE PERSONNEL INFLUENZA VACCINATION FORM.pdf

HEALTH CARE PERSONNEL INFLUENZA VACCINATION FORM 2023-2024 SEASON

I am a VA: Employee Volunteer Other (ex: Trainee, Resident, Intern, Fee Basis, or Researcher) Please indicate your position title: ___________________________________________________________________ CHECK THE APPLICABLE STATEMENT IN ONE OF THE SECTIONS BELOW AND THEN COMPLETE AND SIGN

THE LAST SECTION OF THIS FORM PRIOR TO SUBMISSION TO EMPLOYEE OCCUPATIONAL HEALTH:

1. I received the seasonal influenza vaccine this flu season and I have attached a copy of my documentation to this form.

2. I have been granted a medical exemption from receiving the seasonal influenza vaccine this flu season. I have a medical contraindication for the influenza vaccination as defined by the Centers for Disease Control and Prevention. The reasons for contraindication must be recognized contraindications by the CDC, 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 30th or within two weeks of beginning employment or volunteering, I must wear a face mask according to requirements and guidelines within VHA Directive 1192.01, Seasonal Influenza Vaccination Program for VHA Healthcare Personnel.

Physician Printed Name Physician Address

Physician Signature Date National Provider Identification Number

Supervisor Signature Date Supervisor Email

3. 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 30th or within two weeks of beginning employment or volunteering, I must wear a face mask according to requirements and guidelines within VHA Directive 1192.01, Seasonal Influenza Vaccination Program for VHA Healthcare 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.

Employee / Volunteer Printed Name Last Four Of SS# Position / Department / Service

Employee / Volunteer Signature Date Employee / Volunteer - Email or Cell Phone 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.

VHASYREmployeeHealth@va.gov

ATTACHMENT D.9 RFP 36C24224R0049

https://www.cdc.gov/flu/prevent/whoshouldvax.htm.

mailto:VHASYREmployeeHealth@va.gov