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Name (Print) Last 4 SSN DOB School/lnstitutionSemester20172018 Student Influenza Declination Form I understand that I am at risk for exposure to the influenza virus and may be at risk for developing

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How to fill out 2017-2018 student influenza declination

01

Obtain a copy of the 2017-2018 student influenza declination form from your educational institution.

02

Read the instructions on the form carefully to understand the requirements and conditions.

03

Fill in your personal information, including your full name, student ID, and contact details.

04

Indicate whether you have received the influenza vaccine by checking the appropriate box.

05

Provide the date when you received the vaccine, if applicable.

06

Sign and date the form to certify the accuracy of the information provided.

07

Return the completed form to the designated office or person at your educational institution.

Who needs 2017-2018 student influenza declination?

01

All students who are enrolled in educational institutions and have not received the influenza vaccine for the 2017-2018 academic year are required to fill out the student influenza declination form.

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