School of Nursing
Field Experience Office
Influenza Vaccination Declination Form
Influenza Vaccination Declination Form
I understand it is my responsibility to obtain the influenza vaccine if required by nominated field sites. I also understand
that if I decline the vaccine, this may prevent me from completing practicum at field sites requiring an influenza vaccine.
Printed Name: ___________________________________
Student ID:_______________ Last 4 SSN:___________
I acknowledge I am aware of the following facts about the influenza vaccination:
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Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons
in the United States each year.
Influenza vaccination is recommended for me and all other healthcare workers to protect our patients from influenza
disease, its complications, and death.
If I contract influenza, I will be contagious for 24-48 hours before influenza symptoms appear. Likewise, I can spread
influenza disease to patients as well as all people I come in contact with who are in close proximity to me.
If I become infected with influenza, even when my symptoms are mild or non-existent, I can spread severe illness to others.
I understand that the strains of virus that cause influenza infection change almost every year, which is why a different
influenza vaccine is recommended each year.
I understand that I cannot get influenza from the influenza vaccine.
The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of
those with whom I have contact, including my patients, co-workers, family, and my community.
I am choosing to decline/refuse the influenza vaccination for the following reason(s):
Medical Reasons: (signature of primary care provider required)
□ Allergy to a component of the flu vaccine, including egg allergies
□ Significant reaction to influenza vaccination in the past
□ History of Guillain-Barre syndrome
□ Currently pregnant or breastfeeding
□ Other medical reason – (must specify):
Non-Medical Reasons:
□ Religious/Philosophical Objection
□ Other non-medical reason – (must specify):
□ I understand that I may be denied a practicum rotation and practicum approval if a field site requires Walden
University to attest and or verify me receiving the influenza vaccination.
Student Name
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Signature
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Date Signed
NOTE: For medical declinations, the primary care provider must sign below, confirming the medical reason.
I certify that this student has the above contraindication and request a medical exception from the influenza vaccination.
Primary Care Provide Name
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Signature
Directions: Student must upload this document to account in CastleBranch.
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Date Signed