Flu Declination


AGENCY STAFF FLU VACCINATION ACCEPTANCE/DECLINATION

*Agency Staff are those individuals who report to work at a Genesis HealthCare Center pursuant to an agreement between Genesis and the Individual’s employer.</p

 

I understand that I may be a risk for acquiring influenza and transmitting the virus to others. I have been given the opportunity to be vaccinated with the inactivated influenza vaccine; however, I decline the influenza vaccination at this time. I understand that by declining this vaccine, I continue to be a t risk for acquiring influenza, a serious illness and of transmitting the virus to others. I understand that I can change my mind at a later time and accept vaccination if the vaccine is still available. As required by the Center, I will wear a mask at all times (with the exception of the employee lounge/break room) at the Center. The mask will be supplied by the location at no cost to me.

I DECLINE THE INFLUENZA VACCINE FOR THE FOLLOWING REASON(S) (CHECK ALL THAT APPLY):

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Document name: Flu Declination
lock iconUnique Document ID: 927e71bd43fcb5d4629624157ab79d2e7956dc02
Timestamp Audit
January 24, 2023 4:49 pm EDTFlu Declination Uploaded by Assist Medical Staffing - staff@assistms.com IP 104.128.161.76
February 6, 2023 1:19 pm EDT Document owner richard@assistms.com has handed over this document to staff@assistms.com 2023-02-06 13:19:11 - 104.128.161.231