Get the free Declination of Influenza Vaccination Form - WithinReach WA - withinreachwa

Declination of Influenza Vaccination My employer or affiliated health facility, has recommended that I receive influenza vaccination in order to protect the patients I serve. I acknowledge that I

How to fill out declination of influenza vaccination

How to fill out declination of influenza vaccination:

1. Obtain the declination form: The first step is to obtain the declination form from your healthcare provider or employer. This form is typically provided when you are given information about the influenza vaccination.
2. Read the instructions: Take the time to carefully read and understand the instructions provided on the declination form. This will ensure that you fill it out correctly and provide all the necessary information.
3. Personal information: Write your personal information on the form, which may include your full name, date of birth, address, and contact information. Make sure to provide accurate and up-to-date information.
4. Reason for declining: The declination form will typically have a section where you can indicate the reason for declining the influenza vaccination. Common reasons may include medical contraindications, previous adverse reactions, or personal beliefs.
5. Signature: Sign and date the declination form to acknowledge that you are choosing to decline the influenza vaccination. Make sure to follow any specific instructions regarding the signature, such as signing in ink or using an electronic signature.
6. Return the form: Once you have filled out the declination form, return it to the appropriate individual or department as specified in the instructions. This could be your healthcare provider, employer, or another designated person.

Who needs declination of influenza vaccination?

1. Individuals with medical contraindications: Some individuals may have specific medical conditions or allergies that make them unable to receive the influenza vaccination. In these cases, a declination form may be required to document their inability to receive the vaccine.
2. Individuals with previous adverse reactions: If someone has had a severe allergic reaction or adverse event after receiving the influenza vaccine in the past, they may be advised to decline future vaccinations. A declination form would be necessary to document this decision.
3. Individuals with personal beliefs or preferences: Some individuals may choose to decline the influenza vaccination due to personal beliefs, religious reasons, or simply personal preferences. In these cases, a declination form can be used to communicate their decision and exempt them from the vaccination requirement.

Note: It is important to consult with your healthcare provider or employer to understand the specific requirements and guidelines regarding the declination of influenza vaccination, as they may vary depending on the setting or organization.

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