Employee Influenza Vaccine Declination

Employee Influenza Vaccine Declination
Name

First NameLast Name
Department
I am a...
I have been offered the influenza vaccine and provided with the Influenza Vaccine Information Statement for the current season, and I understand the indications, risks and benefits. I have had the opportunity to ask questions, which have been answered to my satisfaction.
I decline for the following reasons:
Signature
Should be Empty: