Employee Influenza Immunization Declination Form 2012-2013
EMPLOYEE INFLUENZA IMMUNIZATION DECLINATION FORM 2012-2013
HospitalDepartment: / Location: / Employee ID#
Full Name: / Volunteer ID#
PLEASE PRINT CLEARLY
The American Nurses Association, the Minnesota Department of Health, The Joint Commission, and [this hospital] recommend that employees receive influenza vaccine annually. The reasons for getting immunized against influenza are many:
1) Protect yourself. If you get influenza, you can miss a week or more of work and pay.
2) Protect your loved ones. If you get influenza, you can spread it to your family and loved ones. Older people, young children and people with chronic illness are especially vulnerable to getting seriously sick from influenza.
3) Protect your patients and your co-workers. If you get influenza, you can spread it to people you work with, and to patients that you care for. Many of our patients are at high-risk for influenza-related complications, which can result in death. It’s a patient safety issue.
IF YOU DO NOT WISH TO RECEIVE INFLUENZA VACCINE, PLEASE COMPLETE THE FOLLOWING:I realize I am eligible to receive the influenza vaccine free of charge and refusing it may put patients, visitors, and family, with whom I have contact at risk should I contract influenza. Regardless, I do not wish to receive the influenza vaccine. I understand that I may change my mind and receive influenza vaccine, if vaccine is available.
To help us understand why employees refuse influenza vaccine, please check the box or boxes that most closely match your concerns.
Concern / Information regarding concern
I’m healthy. I never get influenza. / Health care personnel are at increased risk for contracting influenza because of exposure from patients. Being healthy will not protect you and if you get influenza you can infect others 1 to 2 days before symptoms develop and up to 5 days after becoming sick. This means you can infect your patients and family before you even know you are sick.
I’m not convinced that influenza vaccine is effective. / Influenza vaccine is most effective in younger, healthy individuals (70-90%). Patients at highest risk including the elderly and the immunocompromised are least likely to develop and adequate response to the vaccine (30-40% effective against illness, 80% effective in preventing death). Therefore vaccination of those individuals who come in contact with our vulnerable population is the most effective strategy for prevention.
I’m concerned about side effects of the vaccine. / The influenza vaccines (injectable and nasal spray) have been studied closely, and serious side effects are very rare. The most common side effect of the injectable influenza vaccine in adults is soreness at the injection site often caused by a person’s immune system making protective antibodies to fight against influenza infection. In adults, side effects from the intranasal vaccine can include runny nose, headache, sore throat and cough.
I’m concerned about getting influenza from the vaccine. / Influenza vaccines cannot cause influenza. The viruses in influenza vaccines are either killed or weakened. The vaccines work by ‘priming your body’s defenses in case you are exposed to an influenza virus. Influenza-like symptoms after receiving influenza vaccine may be caused by:
· Being exposed to influenza virus shortly before getting vaccinated or during the two-week period that it takes the body to gain protection after getting vaccinated. This exposure may result in a person becoming ill with influenza before the vaccine begins to protect them.
· Becoming ill from other viruses (such as rhinovirus).
Other concern(s):
Employee signature: / Today’s Date:
Not a chart form. Send this form to: [fill in location]