Infection Prevention Manual

352&('85(6 *(1(5$/ 5(48,5(0(176 $OO HPSOR\HHV ZLOO EH UHTXLUHG WR REWDLQ WKH LQIOXHQ]D YDFFLQH RU VLJQ WKH GHFOLQDWLRQ RQ WKH Influenza Vaccination Employee Statement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cknowledgement of Receipt IRUP WR WKH 2IILFH RI +XPDQ 5HVRXUFHV $QQXDOO\ FRPSOHWLQJ DQG VLJQLQJ WKH Influenza Vaccination Employee Statement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cknowledgement of Receipt IRUP LQ HPSOR\HHV¶ SHUVRQQHO ILOHV 3URYLGLQJ HDFK HPSOR\HH DQQXDOO\ ZLWK D UHPLQGHU RI WKLV SROLF\ DQG D FRS\ RI WKH Influenza Vaccination Employee Statement IRU WKDW \HDU¶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nfluenza Vaccination Employee Statement IURP DOO HPSOR\HHV 0DLQWDLQLQJ UHFRUGV RI HPSOR\HHV ZKR KDYH UHFHLYHG RU GHFOLQHG LQIOXHQ]D YDFFLQDWLRQ 3URYLGLQJ LQIRUPDWLRQ WR WKH 2IILFH RI +XPDQ 5HVRXUFHV UHJDUGLQJ WKRVH HPSOR\HHV ZKR DUH QRW LQ FRPSOLDQFH ZLWK WKLV SROLF\ 5HYLHZLQJ DQQXDO HPSOR\HH LQIOXHQ]D YDFFLQDWLRQ UDWHV 'HYHORSLQJ DQG UHFRPPHQGLQJ VWUDWHJLHV LQFOXGLQJ UHYLVLRQV WR WKLV SROLF\ WR HQKDQFH DQG LPSURYH LQIOXHQ]D YDFFLQDWLRQ UDWHV LQ WKH 'HSDUWPHQW Your Agency Name (PN System)