Health Care Worker Influenza Vaccination Tracking Form

I understand that receiving the influenza vaccine will help protect the patients I care for from serious complications of influenza, however I will not be vaccinated at this time.

Please initial next to the reason(s) for declining vaccination acknowledging that you have reviewed and understood the educational materials provided.

Initial	Reason	Considerations
	I have a fear of needles.	The nasal spray - LAIV (live attenuated intranasal vaccine) or Flumist may be a good option if you are under the age of 50. Ask your health care provider for more information.
	I am concerned about the safety of the vaccine.	Influenza vaccine has undergone rigorous safety testing, has been determined safe by the FDA, and has a very long standing safety record. Serious adverse reactions are very rare.
	I am not in a high-risk group.	The CDC has made a universal recommendation for flu vaccine, including those individuals who are not at high risk for complications of influenza. Even healthy adults may become seriously ill with influenza. In addition, even if you aren’t in a high risk group most of your patients are at high-risk for complications of influenza and you could easily spread influenza to them if you are not vaccinated.
	I got sick the last time I got a flu shot and I am concerned that I will get the flu from the flu shot.	Some people do get mild flu-like symptoms for a short time after being vaccinated, but this is a sign that your body is responding to the vaccine and giving you protection. It is not the flu. Also, because cold viruses are constantly circulating, it is possible that a person could become ill with a cold at the same time they receive the flu vaccine.
	I never get sick.	Healthy adults may have mild symptoms when they get influenza. But it is possible to spread the influenza virus to patients even if you don’t feel ill or only feel mildly ill.
	I am pregnant or breastfeeding.	Pregnancy increases the risk of serious medical complications of influenza. Pregnant women are among the CDC’s top priority groups for influenza vaccination. Inactivated vaccines, like the flu shot, have not been known to pose a risk to the unborn fetus. Also, recent studies suggest that newborns benefit from the vaccination of their mother. Flu vaccine is safe and recommended for breastfeeding women as well. Breastfeeding women could easily spread influenza to their infant who is at high risk for complications of influenza.
	I have a religious or philosophical opposition to vaccination.	We understand that some individuals oppose vaccination including influenza vaccination. Please understand that it is our mission to provide a safe environment – both for the patients and for employees. Influenza vaccination is a primary prevention activity that we use to accomplish this mission. Please be aware that employees that choose not to be vaccinated may be asked to stay home when they have influenza-like illness (ILI) symptoms. They also may have to wear PPE whenever caring for patients with ILI.
	I have another reason.	Please explain:

Signature:___________________________________________________________       Date:_________________________