| Section 1 - Employee Information |
| * required fields |
| First Name* |
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| Last Name* |
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| Badge ID* |
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| JHED ID |
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| Do you work with patients or in a patient care
area?* |
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| Employment Status* |
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| Division*
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| Department* |
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| Phone |
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| Manager Name |
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Section 2 - Declination of Annual Influenza Vaccination |
| I decline the Annual Influenza Vaccination at Johns
Hopkins** |
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| Decline Reason* |
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| Explain |
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| Did you receive Influenza Vaccination outside of
Hopkins? If yes, please check this box. |
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Where Received?
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When Received?
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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. |
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I have received education about the effectiveness of influenza vaccination
as well as the adverse events. I have also been given the opportunity to be
vaccinated with influenza vaccine, at no charge to myself. |
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However, I
decline influenza vaccination at this time at Johns Hopkins. 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. |
| Before you submit you form you have an
option to print it for your records. Click here to Print a copy of the report.
Please do NOT fax it to
the Occupational Health office. |
| **By hitting the submit button I read and agree with the terms of the
declination. |