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Mt. San Antonio College Child Development Center Influenza Vaccination Written Declination Form I DO NOT WANT A FLU SHOT. I acknowledge that I am aware of the following facts: Influenza is a serious
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How to fill out influenza declination form
01
Obtain the influenza declination form from your employer or healthcare provider.
02
Read the instructions on the form carefully to understand the information needed.
03
Fill out your personal information such as name, date of birth, and contact information.
04
Indicate your reason for declining the influenza vaccine by checking the appropriate box.
05
Sign and date the form to confirm your decision.
06
Return the completed form to the designated individual or department as instructed.
Who needs influenza declination form?
01
Employees who are required to get the influenza vaccine but have a valid reason for declining it.
02
Individuals who are not eligible or have contraindications for the influenza vaccine.
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What is influenza declination form?
Influenza declination form is a document that allows individuals to decline receiving the influenza vaccine.
Who is required to file influenza declination form?
Any individual who chooses not to receive the influenza vaccine is required to file the influenza declination form.
How to fill out influenza declination form?
To fill out the influenza declination form, individuals must provide their personal information and reason for declining the influenza vaccine.
What is the purpose of influenza declination form?
The purpose of the influenza declination form is to document and track individuals who choose not to receive the influenza vaccine.
What information must be reported on influenza declination form?
The information reported on the influenza declination form typically includes the individual's name, contact information, reason for declining the vaccine, and signature.
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