Influenza Vaccination Documentation - 0919

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COMMUNITY PARTNERSHIPS OBSERVATION/JOB SHADOW INFLUENZA VACCINATION DOCUMENTATION or DECLINATION (FOR OBSERVERS 18 YEARS OF AGE AND OLDER) ___________________________________ __________ Name Date ___________________________________ __________ School (if applicable) Date of Birth Providence Health & Services Alaska offers the influenza vaccine free of charge to caregivers, volunteers, students (18 years of age and older), employed & non-employed providers, and contracted employees in accordance with the annual CDC recommendations. By being vaccinated, you are protecting yourself, your patients, your family, and the community. Documentation of Seasonal Influenza Vaccination Influenza Vaccination Date: Where was the vaccination received? PAMC Elsewhere __________________ - Please state where and present documentation **** OR **** Declination of Seasonal Influenza Vaccination I DO NOT WANT A FLU VACCINE. I ACKNOWLEDGE THAT I AM AWARE OF THE FOLLOWING FACTS: - Influenza is a serious respiratory disease that kills an average of 23,607 persons and hospitalizes more than 200,000 persons in the United States each year. - Influenza vaccination is recommended for me and all healthcare workers to protect our patients from influenza disease, its complications, and death. - If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms appear. My shedding the virus can spread influenza disease to patients in this facility. - If I become infected with influenza, even if symptoms ARE absent, minimal or resemble a cold, I can spread severe illness to others. - I understand that the strains of virus that cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year. - I understand that I cannot get influenza from the influenza vaccine. - The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including my patients and other patients in this healthcare setting, including my coworkers, my family, and my community. - Side effects of the vaccine are almost universally mild and of short duration. - I understand that I can change my mind and accept the vaccination at any time during the campaign – Sept-Mar. I am declining the flu vaccine because: My licensed independent practitioner documented allergy or medical contraindication to the components of the vaccine. Of my religious beliefs, including my sincerely held ethical or moral beliefs. ___________________________________________ __________ Signature Date

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