Get the free Influenza Vaccination Exemption Form

This form is used to request an exemption from the seasonal influenza vaccination due to medical contraindications or sincere religious objections. It includes sections for both medical verification by a primary care physician and a declaration of religious objection by the student. The completed form must be submitted between October 1, 2024, and April 1, 2024, and is subject to review by Infection Control and Human Resources.

How to fill out influenza vaccination exemption form

How to fill out influenza vaccination exemption form

1. Obtain the influenza vaccination exemption form from your healthcare provider or local health department.
2. Fill in your personal information, including your name, date of birth, and contact details.
3. Indicate the reason for your exemption request by selecting the appropriate category (e.g., medical, philosophical, religious).
4. If applicable, provide additional documentation or a letter from a healthcare professional supporting your exemption.
5. Review the form for any missing information or errors.
6. Sign and date the form to certify the provided information is accurate.
7. Submit the completed form to the appropriate authority as instructed on the form.

Who needs influenza vaccination exemption form?

1. Individuals with medical conditions that contraindicate vaccination.
2. Those with a history of severe allergic reactions to vaccine components.
3. Individuals who have certain philosophical beliefs or religious objections to vaccinations.
4. Students or employees in settings where vaccinations are mandated but seek exemptions.

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What is influenza vaccination exemption form?

The influenza vaccination exemption form is a document that allows individuals to formally decline or exempt themselves from receiving the influenza vaccine due to medical, religious, or philosophical reasons.

Who is required to file influenza vaccination exemption form?

Individuals who are eligible for influenza vaccination but wish to opt out for specific reasons, such as medical conditions, religious beliefs, or personal convictions, are required to file the influenza vaccination exemption form.

How to fill out influenza vaccination exemption form?

To fill out the influenza vaccination exemption form, individuals must provide their personal information, specify the reason for the exemption, and possibly provide documentation or signatures as required by their institution or employer.

What is the purpose of influenza vaccination exemption form?

The purpose of the influenza vaccination exemption form is to ensure that individuals can formally communicate their reasons for declining the vaccination, while also allowing organizations to maintain accurate records of vaccination status within their population.

What information must be reported on influenza vaccination exemption form?

The information that must be reported on the influenza vaccination exemption form typically includes the individual's name, contact information, date of birth, the specific exemption reason, and any supporting documentation if needed.