Broward Health Declination of Influenza Vaccination 2012-2025 free printable template

DECLINATION OF INFLUENZA VACCINATION ONBOARD HEALTH EMPLOYEES/STUDENTS Broward Health requests that all Medical and Allied Health Staff/Students/Contracted Employees receive an annual Influenza vaccination

How to fill out flu consent and declination

How to fill out Broward Health Declination of Influenza Vaccination

1. Obtain the Broward Health Declination of Influenza Vaccination form from your employer or the relevant health department.
2. Read the instructions on the form carefully to understand your rights and responsibilities.
3. Fill in your personal information, including your name, position, and department.
4. Indicate your reason for declination by checking the appropriate box (e.g., medical reasons, personal beliefs).
5. Provide any additional information required by the form, such as details of prior allergies or reactions to vaccines if applicable.
6. Sign and date the form to certify that the information provided is accurate and that you understand the implications of declining the vaccine.
7. Submit the completed form to your supervisor or the designated health official as instructed.

Who needs Broward Health Declination of Influenza Vaccination?

1. Healthcare workers who are unable or unwilling to receive the influenza vaccination due to medical, religious, or personal reasons.
2. Employees of Broward Health who want to formally document their declination of the influenza vaccine.
3. Individuals seeking exemption from mandatory vaccination policies within the Broward Health system.

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What is Broward Health Declination of Influenza Vaccination?

The Broward Health Declination of Influenza Vaccination is a formal document that allows employees to decline receiving the influenza vaccine while acknowledging the potential risks associated with not getting vaccinated.

Who is required to file Broward Health Declination of Influenza Vaccination?

Employees of Broward Health who choose not to receive the influenza vaccination are required to file the declination form.

How to fill out Broward Health Declination of Influenza Vaccination?

To fill out the Broward Health Declination of Influenza Vaccination, employees need to provide their personal details, including name and position, indicate their decision to decline the vaccine, and sign the document acknowledging their understanding of the associated risks.

What is the purpose of Broward Health Declination of Influenza Vaccination?

The purpose of the Broward Health Declination of Influenza Vaccination is to ensure that employees who choose not to be vaccinated formally acknowledge the risks involved while allowing the organization to maintain an accurate record of vaccination status.

What information must be reported on Broward Health Declination of Influenza Vaccination?

The Broward Health Declination of Influenza Vaccination must report the employee's name, position, the date of declination, reason for declining the vaccine, and a signature confirming the acknowledgment of risks involved.