Delgado Community College
Charity School of Nursing
Influenza Vaccination Declination Form
Students are expected to get an influenza vaccination unless they have a valid contraindication
to decline the vaccination. Being vaccinated or completing the form is mandatory.
Students who decline the influenza vaccination must follow the clinical affiliates’ infection
control policy.
If you will not be receiving an influenza vaccine this season, indicate why:
I have one of the following contraindications to receiving the influenza vaccine:
___ Previous allergic reaction to influenza vaccine
___ Allergy to eggs or other vaccine components
___ History of Guillain-Barre Syndrome after prior influenza vaccination
I am choosing to decline the influenza vaccination right now for the reason listed above. I
understand that I may change my mind at any time and be vaccinated against influenza.
Signature: ____________________________________ Date: ______________________
Print Name: ___________________________________