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20212022 INFLUENZA VACCINE DECLINATION FORM PRINT Names: ___DOB: ___I acknowledge that I am aware of the following facts: Influenza is a serious respiratory disease; on average, 34,000 Americans die

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How to fill out flu shot declaration form

01

Obtain a flu shot declaration form from your healthcare provider or workplace.

02

Fill out your personal information such as name, date of birth, and contact information.

03

Provide details about your medical history, including any allergies or previous adverse reactions to vaccines.

04

Answer questions about your current health status, such as whether you are experiencing any symptoms of illness.

05

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

Who needs flu shot declaration form?

01

Anyone who is required to receive a flu shot as part of their workplace or school policy

02

Individuals with underlying health conditions that put them at a higher risk for flu complications

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What is flu shot declaration form?

The flu shot declaration form is a document used to declare that an individual has received a flu shot.

Who is required to file flu shot declaration form?

All employees and students may be required to file a flu shot declaration form depending on the organization's policy.

How to fill out flu shot declaration form?

To fill out a flu shot declaration form, you need to provide personal information, date of flu shot administration, and sign the form.

What is the purpose of flu shot declaration form?

The purpose of a flu shot declaration form is to track and ensure that individuals have received a flu shot to prevent the spread of influenza.

What information must be reported on flu shot declaration form?

The flu shot declaration form typically requires information such as the individual's name, date of birth, date of flu shot administration, and signature.

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