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									          Template - Declination Form for Influenza Vaccination
                           (Spanish & English)

Why use an influenza vaccination declination form?
An influenza vaccination declination form must be used to comply with the California
Health and Safety Code 1288.7. It can also be used to collect information about why
employees decide not to participate in an organization’s influenza vaccination program,
per Joint Commission expectations.

California Health and Safety Code 1288.7 (based on California SB 739) states that
general acute care hospitals ―annually offer onsite influenza vaccinations, if available, to
all hospital employees at no cost to the employee. Each general acute care hospital
shall require its employees to be vaccinated, or if the employee elects not to be
vaccinated, to declare in writing that he or she has declined the vaccination.‖

The Joint Commission has approved a new Infection Control standard that requires
organizations to offer influenza vaccination to staff and licensed independent
practitioners, applicable to critical access hospitals, hospitals, and long-term care,
effective July 1, 2007. See Standard IC.4.15. This includes an expectation that ―the
organization annually evaluates vaccination rates and reasons for non-participation in
the organization’s immunization program.‖

In addition, two advisory committees to the CDC -- the Healthcare Infection Control
Practices Advisory Committee and the Advisory Committee on Immunization Practices -
- recommend that health care personnel who decline an influenza vaccination for
reasons other than medical contraindications should sign a declination form.

Template and how to use it
Your organization can adapt the attached template as part of an integrated HCW
influenza vaccination effort. It is advisable to have key leadership approve the content of
the form and how you plan to integrate it into your employee vaccination program. Key
elements of success are:

  Visible key leadership endorsement: When the CEO or department manager
   receives his or her flu vaccine, make it a public event. Hold a flu fair, do it during a
   staff meeting or in the lobby with balloons and ice cream for all. Leadership should
   remind staff whenever possible of the benefits of flu vaccination.
 Educate HCWs about the benefits of flu vaccination to themselves, their families and
   patients. Use flyers, posters and newsletters, and discuss during staff meetings and
   informal conversations.
 Bring vaccine to HCWs. Use mobile carts, offer vaccination during all shifts, sponsor
   departmental competitions, offer incentives like movie tickets, etc.
 Free vaccine: Health and Safety Code 1288.7 clearly states that the vaccine must be
   offered at no cost to the employee.
A combination of all these approaches is the most successful. Monitoring reasons
employees decline vaccination
This template has been designed to help you monitor the reasons staff may decline
Employees can select their reasons for declining from the list provided on the
Declination Form. These reasons are numbered 1 through 10. We suggest you use
―Influenza Vaccination Declination Tracking Roster‖ to monitor the reasons that
individuals decide to decline vaccination. You may want to place the signed declination
form in the employee’s personnel form, but this is not mandatory.

Monitoring people’s reasons will help you better plan future programs so more people
will be vaccinated. Tracking those who decline will assist you in identifying personnel
who might require targeted interventions in order to accept vaccination in the future.

Adapting the template:
This template was created in collaboration with several organizational partners affiliated
with the California Adult Immunization Coalition’s (CAIC) NAIAW’07 campaign. For
more information, visit

To adapt the template, please follow the steps listed below.
    Secure organizational approval for the form’s content and its use.
    Consider using the form as a double-sided document (English on one side,
      Spanish on the other) or printing two versions of it.
    Add your organization’s name and logo.
    Feel free to make changes appropriate to your program or organization.
    Depending on your program specifics, you may need to change the location in
      the following sentence, ―If I change my mind, I can receive a free influenza
      vaccination at Employee Health Services so long as the vaccine is available.‖
      The sentence appears at the end of the form.
Influenza Vaccination Declination Form

All employees who choose not to have a flu vaccine must complete the following
documentation according to CA Senate Bill 739 (CA Health and Safety Code
1288.7). This states that employees who choose not to get a flu vaccination must
declare in writing that he or she has declined the vaccination.

I have been offered the influenza vaccination by my employer INSERT NAME OF
EMPLOYER. I understand that because I work in a health care environment I may
place others at risk – patients and co-workers – if I work while infected with the
influenza virus.

I have received, and understand, information given to me about the risks and benefits of the

In declining an influenza vaccination for non-medical reasons, I am aware that:
     The vaccine does not cause influenza illness.
     I can be infected by the influenza virus – but not feel ill – and pass the virus to
       vulnerable patients who are at-risk of complications or death for influenza. I can
       also pass the virus to my family, friends and co-workers.
     Influenza strains change every year and an immunization received in prior years
       does not usually provide immunity to this year’s strain of influenza.
     The vaccine takes about two weeks to reach maximum protection. Therefore, I
       will not be fully protected from catching the flu until that time.

 Reasons I do not wish to be vaccinated against influenza:
 (Circle all that apply.)
 1. I do not believe in vaccines for religious or philosophical reasons
 2. I am concerned about side effects and / or safety
 3. I believe the influenza vaccine gives a person the flu.
 4. I don’t believe the vaccine prevents the flu
 5. It’s not important – ―I never get the flu‖
 6. It’s inconvenient
 7. I received influenza vaccine elsewhere (provide documentation)
 8. I don’t like needles
 9. I have a medical contraindication. Please check one
    9a.  Allergy to eggs
    9b.  Severe allergy to other vaccine component
    9c.  Guillain-Barre Syndrome
 Other, please tell us:

                                Employee  MD  Contractor  Volunteer
Health Care Worker Name (Print)    Type of Employee: Check one

                                          /                /                  /
Health Care Worker Signature               Date Signed     Employee ID Number Date of Birth

If I change my mind, I can receive a free influenza vaccination at Employee Health
Services so long as the vaccine is available.
Forma de rechazo de la vacuna contra la influenza (también conocida como la gripe)

Todos los empleados que elijan no ponerse una vacuna contra la influenza (la
gripe) deben completar el siguiente formulario de acuerdo al Proyecto de ley del
Senado de California 739 (Código de Salud y Seguridad de California 1288.7).
Este código indica que los empleados que elijan no ponerse la vacuna contra la
influenza deben declarar por escrito que él o ella ha rechazado vacunarse.

Mi empleador [ESCRIBA EL NOMBRE DEL EMPLEADOR] me ha ofrecido la
vacuna contra la influenza (la gripe). Entiendo que al trabajar en un ambiente para
cuidados de salud puedo poner a otros en riesgo – pacientes y compañeros de trabajo
– si trabajo mientras que estoy infectado/a con el virus de la influenza (la gripe).

He recibido y entiendo la información que se me ha dado sobre los riesgos y los beneficios
de la vacuna.

Rechazo la vacuna contra la influenza por razones no médicas, y entiendo que:
 La vacuna no causa la enfermedad de la influenza.
 Es posible que pueda estar infectado con el virus de la influenza – pero no sentirme
  enfermo/a – y pasar el virus a pacientes vulnerables en riesgo de tener
  complicaciones o morir a causa de la influenza. También puedo contagiar a mi
  familia, amigos y compañeros de trabajo con el virus.
 El tipo de virus de la influenza cambian todos los años y las vacuna que haya
  recibido los años anteriores por lo general no proporcionan protección contra las
  cepas de influenza de este año.
 La vacuna toma aproximadamente dos semanas para lograr una protección
  máxima. Por lo tanto, no me protegerá completamente contra la influenza hasta
  después de ese tiempo.

 Razones por los cuales no quiero vacunarme: (por favor marque
 todas las respuestas que apliquen)
 1. No creo en las vacunas por razones religiosas o filosóficas.
 2. Me preocupan los efectos secundarios y la seguridad de la vacuna.
 3. Yo creo que la vacuna contra la influenza causa la influenza (la
 4. Yo no creo que la vacuna previene la influenza (la gripe).
 5. No es importante— ―nunca me enfermo de la influenza (la gripe)‖.
 6. Es inconveniente.
 7. Yo recibí la vacuna contra la gripe en otro lugar (muestre
 8. No me gustan las agujas/jeringas.
 9. Tengo una contraindicación médica. Por favor marque su
    9a.  Alergia a los huevos
    9b.  Alergia severa a otros componentes de las vacunas
    9c.  Síndrome de Guillain-Barré
 Otras razones, por favor díganos:

                               Empleador  Médico  Contratista  Voluntario
Nombre del trabajador de cuidado de la salud (en imprenta) Tipo de trabajador: Escoja

                             /              /                             /
Firma de profesional de la salud                              Fecha de firma      Número de
ID del trabajador           Fecha de nacimiento

Si cambio de parecer, puedo recibir una vacuna contra la influenza (la gripe) gratuita en
los Servicios de Salud para el Trabajador mientras tanto la vacuna esté disponible.

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