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2019/2020 Flu Vaccine Declination

  • No Place Like Home encourages and offers, free of charge, annual flu vaccinations for all employees.

  • You have the right to refuse vaccination and to do so you must complete the following form each year.

  • Please read carefully and complete ALL entries on this page to decline flu vaccination.

The following boxes must be initialed to complete this form...

I understand that:

The influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and harm.

The strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time, and vaccination against influenza is recommended each year.

I cannot get influenza from the influenza vaccine itself.

If I decide that I want the vaccine I will notify NPLH or my physician & obtain the vaccine (if the vaccine is still available for the current season).

Reason for declining:


(SPECIFIC reason for declining)

Electronically sign your request:

By entering the following electronic signature you attest to the following statement:

have been offered, at no charge, the annual flu vaccine; however, I wish to decline vaccination. I may reverse this decision at any time during the current season by contacting No Place Like Home and requesting vaccination provided that the vaccine is still available at such time.

First name: Last name:

Date of birth: / / (mm/dd/yyyy)

Last 4 digits of SSN:


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