[MCOH-EH] Flu vaccine declination form

[Spooner, Debi]

I just copied the word doc into the email. Then you can cut and paste to create your own. I removed our hosp logo.


 



Deborah A Spooner PA-C 
Employee Occupational Health Services 

Baltimore Washington Medical Center


 



 


                         Declination of Annual Influenza Vaccination


 <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 

            I understand that due to my occupational exposure, I may be at risk of acquiring influenza infection. In addition, I may spread influenza to my patients, other healthcare workers, and my family, even if I have no symptoms. This can result in serious infection, particularly in persons at high risk for influenza complications.

 

          I have received education about the effectiveness of influenza vaccination as well as the adverse events. I have been given the opportunity to be vaccinated with influenza vaccine, at no charge to myself. However, I decline influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring influenza, potentially resulting in transmission to my patients. If in the future I want to be vaccinated with influenza vaccine, I can receive the vaccine at no charge to me. 

 

 

 I am declining due to the following reasons:  (check all that apply)

          ____ I have already been vaccinated this year (attach documentation)

          ____ I am allergic to components of the vaccine _________________

          

          ____ Other _______________________________________

                    ___________________________________________

 

Employee's Name: ________________________  ID # ______________ 

 

Department _________________________ Job Title ___________________

 

Employee's Signature __________________________ Date _____________ 

 

Witness Name ______________________________

 

Witness Signature ___________________________      Date _____________
 
 
 
 
 

-----Original Message-----
[Spooner, Debi] 
 
 
 
 
 
 
From: mcoh-eh-bounces at mylist.net [mailto:mcoh-eh-bounces at mylist.net]On Behalf Of Sullivan, Pat
Sent: Thursday, October 13, 2005 9:56 AM
To: 'MCOH/EH'
Subject: RE: [MCOH-EH] Flu vaccine declination form



Could you attach it to an e-mail and we could all have it? 
Thanks 


Pat Sullivan MSN,RN 
Vassar Brothers Medical Center 
Poughkeepsie, New York 

-----Original Message----- 
From: mcoh-eh-bounces at mylist.net [ mailto:mcoh-eh-bounces at mylist.net]On 
Behalf Of Gigi Dues 
Sent: Thursday, October 13, 2005 8:15 AM 
To: mcoh-eh at mylist.net 
Subject: Re: [MCOH-EH] Flu vaccine declination form 


We are required by AOA to begin using one this year. 
I'll be glad to share our form.  
Does anyone else need it, or shall I just fax it to Dr. Thorne? 

Gigi Dues RN 
Employee Health Dept. 
Grandview Hospital 
Dayton, Ohio 

>>> CTHORNE at umm.edu 10/13/05 07:58AM >>> 
Good morning. Is anyone using a flu vaccine declination form? If so, 
kindly forward a copy if you can. 
  
Many thanks. 
  
Craig D. Thorne, M.D., MPH, FACP, FACOEM 
Medical Director, Employee Health and Safety 
University of Maryland Medical Center 
22 South Greene St., Suite T1R05 
Balitmore, Maryland 20101 
410 328-0957 
410 328-6319 Fax 


  
  
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If you have received this information in error, please immediately contact the Kettering Medical Center Network representative whose number is listed on the message and destroy all evidence of this correspondence.

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