Broward Health Seasonal Influenza AttestationDeclination Form free printable template

Seasonal Influenza Attestation/Declination Form Broward Health has recommended that I receive influenza vaccination annually in order to protect myself and the patients I serve. I acknowledge that

How to fill out attestation declination fillable form

How to fill out Broward Health Seasonal Influenza Attestation/Declination Form

1. Obtain the Broward Health Seasonal Influenza Attestation/Declination Form from the designated source.
2. Read the instructions carefully to understand the purpose of the form.
3. Fill out your personal information at the top of the form, including your name, position, and department.
4. Indicate whether you are attesting to receiving the seasonal influenza vaccine or if you are declining it.
5. If you are attesting, provide the date you received the vaccine and the name of the vaccine provider.
6. If you are declining, provide a brief explanation for your decision in the designated section.
7. Review the completed form for accuracy and completeness.
8. Sign and date the form at the bottom.
9. Submit the form to your supervisor or the designated personnel as instructed.

Who needs Broward Health Seasonal Influenza Attestation/Declination Form?

1. All employees and volunteers at Broward Health who are required to receive the seasonal influenza vaccine or provide a valid reason for declining.

People Also Ask about flu declination form cdc

Can you decline flu vaccine?

Covered Individuals who choose to decline influenza vaccination must complete a Vaccine Declination Letter and submit it to the location vaccine authority on or before December 1, 2022.

What is the CDC statement on flu vaccine?

Flu vaccine prevents millions of illnesses and flu-related visits to the doctor each year. CDC recommends everyone 6 months and older get vaccinated every flu season. Children 6 months through 8 years of age may need 2 doses during a single flu season. Everyone else needs only 1 dose each flu season.

Who regulates the flu vaccine?

The Food and Drug Administration (FDA) is responsible for regulating vaccines in the United States.

How to decline the flu shot for religious reasons?

Religious objections to vaccinations must be sincere to be protected. Religious views that are expressed abruptly will be viewed suspiciously. Clinicians should not attempt a religious objection to vaccination if they don't have a history of those beliefs to back it up.

What is a valid reason to decline the flu shot?

Children younger than 6 months of age are too young to get a flu shot. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine. This might include gelatin, antibiotics, or other ingredients.

How to opt out of the flu vaccine?

Vaccine Declination. Covered Individuals who choose to decline influenza vaccination must complete a Vaccine Declination Letter and submit it to the location vaccine authority on or before December 1, 2022.

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What is Broward Health Seasonal Influenza Attestation/Declination Form?

The Broward Health Seasonal Influenza Attestation/Declination Form is a document that allows employees to either attest that they have received the seasonal influenza vaccination or decline to receive it for various reasons.

Who is required to file Broward Health Seasonal Influenza Attestation/Declination Form?

All employees, clinical staff, and volunteers who are involved in patient care or have direct contact with patients are required to file the Broward Health Seasonal Influenza Attestation/Declination Form.

How to fill out Broward Health Seasonal Influenza Attestation/Declination Form?

To fill out the form, individuals need to provide their personal information, select whether they have received the influenza vaccine or are declining it, and sign the form to confirm the accuracy of their statements.

What is the purpose of Broward Health Seasonal Influenza Attestation/Declination Form?

The purpose of the form is to ensure that Broward Health complies with health regulations, enhances patient safety, and monitors vaccination rates among staff to reduce the risk of influenza outbreaks.

What information must be reported on Broward Health Seasonal Influenza Attestation/Declination Form?

The form must report the individual's name, job title, department, whether they received the vaccine or are declining it, the date of vaccination (if applicable), and a signature to confirm the information provided.