Get the free Seasonal Influenza Vaccine Consent/Waiver/Declination Form - rochestergeneral

Esta es una forma obligatoria que debe ser completada por todo el personal que esté en contacto directo con pacientes para programar trabajo más allá del 14 de diciembre de 2012. La forma aborda

How to fill out seasonal influenza vaccine consentwaiverdeclination

How to fill out Seasonal Influenza Vaccine Consent/Waiver/Declination Form

1. Obtain the Seasonal Influenza Vaccine Consent/Waiver/Declination Form from your healthcare provider or institution.
2. Fill in your personal details including your name, date of birth, and contact information in the specified sections.
3. Read the information provided about the flu vaccine, including potential benefits and risks.
4. Indicate your preference regarding the vaccine by checking the appropriate box (Consent, Waiver, or Declination).
5. If consenting, provide any additional required information, such as medical history or allergies.
6. Sign and date the form at the bottom to indicate your agreement and understanding.
7. Submit the completed form to the designated personnel at your healthcare facility or institution.

Who needs Seasonal Influenza Vaccine Consent/Waiver/Declination Form?

1. Individuals seeking to receive the seasonal influenza vaccine who need to provide consent.
2. Those who wish to waive or decline the influenza vaccine for medical, personal, or other reasons.
3. Employees or students in certain institutions that require a documented consent or declination for vaccination.

People Also Ask about

What is a religious reason for not getting the flu shot?

There are medical reasons that the flu shot is not for everybody- are called medical exemptions. You should not get the flu shot if you have a documented severe allergy to the vaccine or any vaccine component or if you have a history of Guillain-Barré Syndrome within 6 weeks of a receiving a flu shot.

What are valid reasons to decline the flu shot?

California removed its personal and religious exemption option in 2015. Parent/guradian must complete an online educational module to receive a non-medical exemption. Connecticut removed its religious exemption option in 2021.

What are valid reasons to decline the flu vaccine?

document the refusal of one or more recommended immunizations.

How to get a religious exemption for flu vaccine?

DECLINE: I do not want the flu vaccination given to me because of a sincerely held religious reason. I realize that my refusal may put patients, visitors, and family at risk. By declining the influenza vaccine, I understand I am at risk of acquiring influenza.

What are religious reasons for not being vaccinated?

Objection to vaccination was also related to: faith in divine protection and healing for Protestants, Catholics, Jewish and Muslims (10); the use of aborted fetal cells for vaccines' production among Amish and Catholic communities (including during the COVID-19 outbreak when Senior Catholic leaders from the US and

For pdfFiller’s FAQs

What is Seasonal Influenza Vaccine Consent/Waiver/Declination Form?

The Seasonal Influenza Vaccine Consent/Waiver/Declination Form is a document that outlines an individual's consent to receive the seasonal influenza vaccine, or a waiver or declination if they choose not to receive the vaccine.

Who is required to file Seasonal Influenza Vaccine Consent/Waiver/Declination Form?

Individuals, typically employees or students in environments such as schools or healthcare organizations, may be required to file this form to indicate their choice regarding the seasonal influenza vaccine.

How to fill out Seasonal Influenza Vaccine Consent/Waiver/Declination Form?

To fill out the form, individuals typically need to provide personal information, indicate their consent or declination, and possibly provide a reason for their decision, as well as sign and date the document.

What is the purpose of Seasonal Influenza Vaccine Consent/Waiver/Declination Form?

The purpose of the form is to ensure that individuals are informed about the vaccine, to obtain their consent for vaccination, or to formally document their refusal to receive the vaccine.

What information must be reported on Seasonal Influenza Vaccine Consent/Waiver/Declination Form?

The form typically requires individuals to report their name, contact information, date of birth, the date of the form, their vaccination choice (consent or declination), and any applicable reasons for not receiving the vaccine.