Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 956 - HEALTH CARE EMPLOYEE VACCINATION CODE
Appendix A - Sample Declination Form

1. _____ (Initial) I have read the "Influenza Vaccine Information Statement, date XXXX". I have had an opportunity to ask questions, which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine.

Print Name __________________ Department __________________

I intend to be vaccinated.

2. _____ (Initial) I have already had an influenza vaccination this year.

Location where vaccinated _____________ Date vaccinated _____________

3. I acknowledge that I am aware of the following facts:

* Influenza is a serious respiratory disease that kills, on average, 36,000 Americans every year.

* Influenza virus may be shed for up to 48 hours before symptoms begin, allowing transmission to others.

* Up to 30% of people with influenza have no symptoms, allowing transmission to others.

* Influenza virus changes often, making annual vaccination necessary. Immunity following vaccination is strongest for 2 to 6 months.

* I understand that influenza vaccine cannot transmit influenza. It does not, however, prevent all disease.

* I have declined to receive the influenza vaccine for the ______ season. I acknowledge that influenza vaccination is recommended by the Centers for Disease Control and Prevention (CDC) for all health care employees to prevent infection from and transmission of influenza and its complications, including death, to patients/residents/clients, my co-workers, my family and my community.

4. I decline the offer of vaccination for the following reasons (please initial all that apply):

____________ My religious beliefs prohibit vaccination.

____________ I have a medical contraindication to receiving the vaccine.

____________ I have already received an influenza vaccination.

5. Knowing the facts set forth above, I choose to decline vaccination at this time. I may change my mind and accept vaccination later, if vaccine is available. I have read and fully understand the information on this declination form.

Print name _______________ Department _______________

Signature _______________ Date ____________________