Flu Vaccine Declination Form Template
Capture patient decisions on flu vaccination with ease
As a healthcare provider, you know that not everyone will accept the flu vaccine. This flu vaccine declination form template is designed to help you efficiently collect and document patients' decisions to decline the shot. By using this template, you can streamline your office's processes, ensure compliance with record-keeping requirements, maintain clear communication with patients, and support their health choices. Plus, our WCAG-aligned labels make it accessible for everyone. Explore this live template and start simplifying your patient forms today.
When to use this form
Use this form when you need a clear, signed record that an employee, patient, or student chose not to receive the seasonal influenza shot. It helps hospitals and clinics document informed refusal at check-in, pharmacies collect declinations at the register, and employers track staff who opt out so you can apply masking or reassignment policies. For a complete record, pair this with an Immunization record form. If your organization also manages COVID-19 opt-outs, use the COVID-19 Vaccine declination form to keep workflows consistent. When someone requests a broader exemption beyond influenza, refer them to a Vaccine waiver form. The result is clean documentation, fewer follow-ups, and a defensible audit trail during flu season and accreditation reviews.
Must Ask Flu Vaccine Declination Questions
- What is your primary reason for declining the influenza vaccine?
Understanding whether the reason is medical, religious, or personal helps you apply the right policy and follow-up. It guides whether documentation or alternatives are required.
- Have you received vaccine information and do you acknowledge the risks of not being vaccinated?
This documents informed refusal, reducing confusion and liability. If a parent or guardian is signing for a minor, you can capture authority with a Medical authorization form.
- What is your role and work or study setting?
Job and environment (direct patient care, long-term care, school) determine exposure risk and any masking or reassignment rules. Clear context also improves reporting and audits.
- Do you agree to follow alternative precautions during flu season, such as masking and staying home when ill?
Agreement gives you a basis to enforce safety steps that protect patients, residents, and coworkers. It also sets expectations if outbreaks require temporary reassignment.
- What is your flu vaccination history this season and have you had any prior adverse reactions?
Recent doses and reactions help distinguish contraindications from preference and may prompt medical review. Accurate history also supports contact with occupational health if your status changes later.
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