Infection Prevention Manual

Employee Influenza Vaccination Policy Acknowledgement of Receipt Please print your name and title and then sign and date the form to indicate that you have received a copy of the Agency’s Policy for the Administration of Influenza Vaccine to Agency’s Employees . You are responsible for reading and adhering to the policy. __________________________ _______________________________ Print Name/Title Signature __________________________ Date Please send signed Acknowledgement of Receipt form to: Office of Human Resources. Influenza Vaccination Employee Statement I am aware of the influenza policy and have had a chance to have my questions answered about influenza vaccination. * I understand the benefits and risks of the vaccine, and: I agree to have the influenza vaccine for the influenza season. If you have already received the influenza vaccine for this influenza season, please specify the date____________. I decline influenza vaccination for the influenza season. I understand that I may rescind this declination at any time. Please specify reason(s) for the declination __________________________________. ____________________________ _________________________ Signature Date _____________________________________________________ Printed Name/Title Did you receive the influenza vaccine during last year’s influenza season? Yes No * For questions about influenza vaccination, please call the Agency. If Administration was at the Agency location: Administration of Vaccine: LAIV TIV Date: ____________________ Administer by RN: ______________________________________ Signature: _____________________________ Your Agency Name (PN System)