Declination of Influenza

Summit Home Care as well as the NYS Department of Health has recommended that I receive the influenza vaccination because I work in a health care environment, I may place others at risk; patients and coworkers if I work while infected with the influenza virus.

I have received, and understand, information given to me about the risks and benefits of the vaccine.

In declining an influenza vaccination for non-medical reasons, I am aware that:

    Reasons I do not wish to be vaccinated against influenza: (Check all that apply.)

    1. I do not believe in vaccines for religious or philosophical reasons

    2. I am concerned about side effects and / or safety

    3. I believe the influenza vaccine gives a person the flu

    4. I don’t believe the vaccine prevents the flu

    5. It’s not important – “I never get the flu”

    6. It’s inconvenient

    7. I don’t like needles

    8. I have a medical contraindication. Please check one

      1. Allergy to eggs

      2. Severe allergy to other vaccine component

      3. Guillain-Barre Syndrome

    I understand that by declining the Flu Vaccine I MUST WEAR a face mask at ALL times when with a patient.
    If I am NOT wearing a face mask and a representative from Summit Home Care should visit my patient's home, I understand that I will be TERMINATED IMMEDIATELY.

    I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.

    I have read and fully understand the information on this declination form.

    Skip to content