Assist Medical Staffing

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

Declination

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):

I have already received the flu vaccine elsewhere this season and provided the documentation.

I have a medical contraindication/condition of severe allergic reaction to eggs.

I have been offered the eggless vaccine, Flu Block, if under 50 years of age and still decline.

I have a medical contraindication/condition of severe allergic reaction to other component(s) of the vaccine, or history of Guillain-Barre Syndrome within 6 weeks after a previous influenza vaccination and cannot accept the influenza vaccine.

Perceived ineffectiveness of the vaccine. According to CDC Studies, the inactivated influenza vaccine showed significant effectiveness against laboratory confirmed influenza among healthy persons and those with high-risk medical conditions. Decreased hospitalization and decreased death from flu complications was also noted.

Fear of vaccine side effects. Side effects are usually mild and include low grade fever and aches. The most common side effects include: soreness, redness and stiffness at the site of the infection.

Fear of contracting influenza/influenza-like illness from the vaccine. The flu viruses are inactivated and therefore cannot cause the flu.

Religious accommodation

Other

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Document name: Flu Declination

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January 24, 2023 4:49 pm EDT

Flu 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

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