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

I do not believe in vaccines for religious or philosophical reasons

I am concerned about side effects and / or safety

I believe the influenza vaccine gives a person the flu

I don’t believe the vaccine prevents the flu

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

It’s inconvenient

I don’t like needles

medical contraindication (specify below)

I have a medical contraindication to the vaccine:

Allergy to eggs

Severe allergy to other vaccine component

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.

*

Caregiver Code *

Date of submission *

Signature *

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