Flu Declination Form – Emergency Medical Services University, LLC

Flu Declination From

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My Institute, Emergency Medical Services University LLC, recommends that I receive influenza vaccination to protect myself, patients, staff and other in the healthcare facilty.

I acknowledge that I am aware of the following facts.

Please read below and place initial for each box.

Influenza is a serious respiratory disease. Each year in the United States, influenza kills thousands of people

Influenza vaccination is recommended for me and all other healthcare personnel to protect our staff and our facility's patients from influenza, its complications, and death.

If I contract influenza, I can shed the virus for 24 hours before any influenza symptoms appear. During the time I shed the virus, I can transmit influenza to patients and staff in this facility.

If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread influenza to others. Symptoms that are mild or non-existent can cause serious illness and death to others.

I understand that the strains of virus that cause infection changes almost every year and, even they do not change, my immunity declines over time. This is why vaccinations against influenza is recommended every year.

I understand that it is impossible to get influenza from influenza vaccine.

The consequences of my refusal to be vaccinated could have life-threatening consequences for my health and the health of everyone with whom I have contact, including my coworkers and all patients in this healthcare facility..

I understand that I can change my mind at any time and accept influenza vaccination.

Name

First

Last

Student ID

Mandatory! Please enter the correct number to receive credit. EMT student ID's are usually in this format: 123456FT-01 and are located in your email. If you do not know the number, meet Customer Service in Live Chat or call (800) 728-0209.

I time. declines

Date

Signature

Clear Signature

I have read and fully understand the information on this declination form.

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