Get the free Influenza Vaccine Declination Form For Students
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Information is mandatory. Name School Last 4 of SSN Program DOB Vaccine date Revised September 7 2016. However I decline the influenza vaccine at this time. I understand that by declining the vaccine I may continue to be at risk for influenza infection. Should I decide that I want to be vaccinated with the influenza vaccine I should notify Employee Health and I can receive the vaccine if available at no charge. INFLUENZA VACCINE DECLINATION FORM FOR STUDENTS The healthcare facility has...
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How to fill out influenza vaccine declination form
How to fill out influenza vaccine declination form
01
First, obtain the influenza vaccine declination form from your healthcare provider or employer.
02
Read the instructions and information provided on the form carefully.
03
Fill out your personal information accurately, including your full name, date of birth, and contact details.
04
Review the section that outlines the risks and benefits of receiving the influenza vaccine.
05
If you have any medical conditions or concerns, consult with your healthcare provider before making a decision.
06
Indicate your decision to decline the influenza vaccine by checking the appropriate box or marking the provided space.
07
Sign and date the form to validate your declination.
08
Return the completed form to your healthcare provider or employer as instructed.
09
Ensure that you retain a copy of the completed form for your own records.
Who needs influenza vaccine declination form?
01
The influenza vaccine declination form is typically needed by individuals who are eligible for the vaccine but have chosen not to receive it.
02
People who may need this form include healthcare workers, students, or employees who are required to show proof of influenza vaccination.
03
It is important to check with your specific healthcare provider, employer, or educational institution to determine their guidelines and requirements for the influenza vaccine declination form.
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What is influenza vaccine declination form?
The influenza vaccine declination form is a document used by individuals to officially decline receiving the influenza vaccine.
Who is required to file influenza vaccine declination form?
Individuals who choose not to receive the influenza vaccine are required to file the influenza vaccine declination form.
How to fill out influenza vaccine declination form?
To fill out the influenza vaccine declination form, individuals must provide their personal information and reason for declining the vaccine, then sign and date the form.
What is the purpose of influenza vaccine declination form?
The purpose of the influenza vaccine declination form is to document an individual's decision to decline receiving the influenza vaccine.
What information must be reported on influenza vaccine declination form?
The influenza vaccine declination form must include the individual's name, contact information, reason for declining the vaccine, and signature.
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