Refusal to Receive Flu Vaccination – English

I, the employee listed herein, acknowledge the following:

1. That I have yet to receive the seasonal flu shot/spray, have received the flu shot but can’t provide proof at this time or decline to receive the flu shot/spray.

2. That I have received an adequate amount of masks from ACS Home Care LLC to handle my current case load during the flu season. In the event that I need additional masks to perform my duties I will contact the agency in advance to supply me them or I will purchase them myself.

3. I have been shown and I demonstrated competency in the use donning and doffing of masks.

4. I am aware that if I am found to be non-compliant with wearing of a mask during patient care or within 6 feet of the patient during influenza season, a written warning will be given for the first offense. I am aware that a second offense will result in termination.


Links to relevant information:

   a. Influenza/Pneumococcal Immunization Consent Form (https://www.health.ny.gov/forms/doh-4156.pdf)

   b. DOH Form: You need a seasonal flu shot or the seasonal flu-spray vaccine every year (in English and Spanish text) (https://www.health.ny.gov/publications/2438/)

   c. CDC form: Vaccine Information Statement, Influenza Vaccine, What You Need to Know (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf)

   d. CDC Form : Sequence For Removing Personal Protective Equipment (PPE) (in English and Spanish text) (https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf)

   e. National Foundation for Infectious Diseases notice titled: Attention! Attention! All Healthcare Workers! THIS IS NOT A TEST This is an important Notice about Common Misconceptions of Influenza (https://www.nfid.org/infectious-diseases/myths-and-facts-about-influenza-for-consumers/)



6. I had the opportunity to ask all questions in regards to all the above and I know where to go if I have any other additional questions.

_____________________________________________________________________________

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement(s) explaining the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss the statements and have my questions answered by a healthcare provider. I understand the following:

• The purpose of the need for the recommended vaccine.

• The risks and benefits of the recommended vaccine.

• While the CDC Advisory Committee on Immunization Practices, and the New York State Department of Health have strongly recommended that the vaccine be given to all persons who have been screened and determined to be candidates for the vaccine, my employer’s policy is mandatory influenza vaccination as a condition of employment.

• I understand that I cannot get the flu from the influenza vaccine.

Nevertheless, I have decided to decline the vaccine recommended as indicated above. My reason for declining the influenza (flu) vaccine is (please type your reason below):

I know that failure to follow the recommendations about vaccination may endanger my health, and the health of others I may come in contact with should I become infected.

I know that I may re-address this issue with my health care provider at any time and accept vaccination in the future.

I acknowledge that I have read this document in its entirety and fully understand it.