Policy Manual sample

MDT Home Health Care Agency, Inc. 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: 9 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____________. 9 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? 9 Yes 9 No *For questions about influenza vaccination, please call the Agency. If Administration was at the Agency location: Administration of Vaccine: 9 LAIV 9 TIV Date: ____________________ Administer by RN: ______________________________________ Signature: _____________________________ Home Health Agency. - - Personnel/Operations Policies B-161