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I do not like needles. My philosophical or religious beliefs prohibit vaccination. I have an allergy or medical contraindication to receiving the vaccine. DECLINATION FORM FOR SEASONAL INFLUENZA VACCINE Name printed 3-4 ID or SSN Facility Department My employer has recommended that I receive influenza vaccination in order to protect myself and the patients I serve. I have declined to receive the influenza vaccine for the 2016-2017 season. I acknowledge that influenza vaccination is...

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