S02 Healthcare Personnel Influenza Vaccination Form.pdf

B-1

September 26, 2017 VHA DIRECTIVE 1192

APPENDIX B

HEALTH CARE PERSONNEL INFLUENZA VACCINATION FORM

I am a VA: ___Employee ___ Volunteer ___ Trainee (residents, interns and students)

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

I decline to receive seasonal influenza vaccine at this time for the following reason:

Select the single answer that best fits your reason:

I do not like needles.

I have a philosophical or religious reason for not receiving the vaccine.

I have an allergy to the vaccine or one of its components.

I am concerned about the side effects/safety of the vaccine.

I have never had the flu and don’t think I will this season.

I have another reason. (Please explain)

I acknowledge that VHA policy requires health care personnel to receive the influenza vaccine every year. I understand that if I decline to receive the vaccine and/or to provide proof of vaccination by November 30 or within two weeks of beginning employment if after November 30, I must wear a face mask according to requirements and guidelines within the Directive 1192, Seasonal Influenza Prevention Program. I understand that violation of the directive may result in disciplinary action.

I have read and fully understand the information on this form and have been given the opportunity to have my questions answered.

Signature: ______________________________ Date: ___________

Name (print): _____________________________ Last 4 SS# _______

Dept./Serv: ____________________ Supervisor: ___________________

Employees and volunteers provide this form to the facility Employee Occupational Health Office.

Trainees provide this form to the Designated Education Officer.

Contractor

HEALTH CARE PERSONNEL INFLUENZA VACCINATION FORM