Influenza Declination Form Template
Streamline Vaccination Preferences with Our Flu Declination Form
If you're looking to respect individual choices about flu vaccinations, this declination form template is designed for you. Perfect for businesses, healthcare facilities, and educational institutions, it ensures that users can easily decline the flu vaccine while maintaining compliance with health regulations. You can improve documentation accuracy, simplify record-keeping, and provide clear communication about vaccination policies, all while adhering to WCAG-aligned accessibility standards. Explore this template and see how it meets your needs.
When to use this form
Use this when your organization needs a signed record from staff, students, or volunteers who choose not to receive the seasonal flu vaccine. It fits onboarding, annual compliance, and outbreak response. Healthcare employers, long-term care facilities, schools, and home health agencies benefit from clear documentation of the reason, risk acknowledgment, and required precautions. If someone gets vaccinated later, direct them to submit the Flu shot proof form. For broader policy tracking, pair this with the COVID-19 Vaccine self-certification form. For minors in schools or camps, you may also collect a Child medical consent form. The result is a consistent process that supports safety, accommodations, and audit-ready records.
Must Ask Influenza Declination Questions
- What is your reason for declining the influenza vaccine?
Knowing whether the reason is medical, religious, prior reaction, or personal preference helps you apply the right policy and accommodations. Clear categories reduce back-and-forth and speed up approvals.
- Do you work in a role with direct patient or resident contact, and where do you primarily work?
Exposure risk depends on job duties and location, so this guides masking, testing, or temporary reassignment. It also helps infection control prioritize high-risk units.
- Do you acknowledge the risks of influenza and agree to follow required precautions (masking, hygiene, staying home when sick)?
This attestation shows the person understands the risk and your safety rules. It sets clear expectations for compliance and accountability.
- Are you requesting a medical or religious accommodation, and can you provide supporting documentation if needed?
This clarifies whether to route the request to HR, employee health, or legal for review. If medical records must be shared, request consent using the HIPAA Authorization form.
- What dates does this declination cover for the current flu season, and how can we reach you if policy changes?
Defining the effective period keeps your records accurate and aligned with the current season. Contact details enable timely follow-up, renewals, or updates if guidance shifts.
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