INFLUENZA VACCINATION CONSENT / WAIVER FORM
Do not accept the influenza vaccine if:
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You have had a previous allergic and/or serious reaction to the vaccine
You currently have moderate to severe acute illness with fever
The following information is required:
1.
2.
3.
4.
5.
6.
The date of your last influenza vaccine:
Are you allergic to eggs?
Have you ever had a serious reaction to a flu shot?
Are you sick with a fever?
Have you ever had Guillain-Barre Syndrome?
Are you pregnant or breastfeeding?
____________________
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
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I understand that due to my occupational exposure to potentially infectious material, I am at
risk of acquiring influenza infection. I have read the Employee Information Sheet: Influenza
Immunization and have had an opportunity to ask questions which were answered to my
satisfaction. I understand the risks and benefits and have been given the opportunity to be
vaccinated.
Having been so informed:

I decline the influenza vaccine
Employee Name
☐ By checking this box, I am certifying this as my electronic signature typed below.
Employee Signature
The Aspen Group
Date
July 2012
3.16A
Employee Information Sheet: Influenza Immunization
Healthcare entities and healthcare workers have a shared responsibility to prevent the spread of
infection and avoid causing harm to their patients by taking reasonable precautions to prevent the
transmission of vaccine-preventable diseases. Vaccine programs are, therefore, an essential part
of infection prevention and control for slowing or stopping the transmission of seasonal
influenza viruses from adversely affecting those individuals who are most susceptible.
Influenza is primarily a community-based infection that is transmitted in households and
community settings. Each year, 5% to 20% of U.S. residents acquire an influenza virus
infection, and many will seek medical care in ambulatory healthcare. In addition, more than
200,000 persons, on average, are hospitalized each year for influenza-related complications.
Healthcare-associated influenza infections can occur in any healthcare setting and are most
common when influenza is also circulating in the community.
Uncomplicated influenza illness is characterized by the abrupt onset of constitutional and
respiratory signs and symptoms (e.g., fever, myalgia, headache, malaise, nonproductive cough,
sore throat, and rhinitis).
Preventing transmission of influenza virus and other infectious agents within healthcare settings
requires a multi-faceted approach. Spread of influenza virus can occur among patients, health
care providers, and visitors; in addition, health care providers may acquire influenza from
persons in their household or community.
The most effective strategy for preventing influenza is annual vaccination. Achieving high
influenza vaccination rates of health care providers and patients is a critical step in preventing
healthcare transmission of influenza from health care providers to patients and from patients to
health care providers. According to current national guidelines, unless contraindicated,
vaccination is recommended for all people aged 6 months and older, including health care
providers, patients and residents of long-term care facilities.
During the care of any patient, all health care providers in every healthcare setting should adhere
to standard precautions, which are the foundation for preventing transmission of infectious
agents in all healthcare settings. Standard precautions assume that every person is potentially
infected or colonized with a pathogen that could be transmitted in the healthcare setting.
Elements of standard precautions that apply to patients with respiratory infections, including
those caused by the influenza virus include, but are not limited to:
 Frequent hand hygiene, including before and after all patient contact, contact with
potentially infectious material, and before putting on and upon removal of personal
protective equipment, including gloves.
 Wearing gloves for any contact with potentially infectious material. Remove gloves after
contact, followed by hand hygiene.
 Wearing gowns for any patient-care activity when contact with potentially infectious
material (including respiratory) is anticipated. Remove gown and perform hand hygiene
before leaving the patient's environment.
The Aspen Group
July 2012
3.16A
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Droplet precautions should be implemented for patients with suspected or confirmed
influenza for 7 days after illness onset or until 24 hours after the resolution of fever and
respiratory symptoms, whichever is longer. In some cases, agencies may choose to apply
droplet precautions for longer periods based on clinical judgment, such as in the case of
young children or severely immuno-compromised patients, who may shed influenza virus
for longer periods of time.
Health care providers at higher risk for complications from influenza infection include pregnant
women and women up to 2 weeks postpartum, persons 65 years old and older, and persons with
chronic diseases such as asthma, heart disease, diabetes, diseases that suppress the immune
system, certain other chronic medical conditions, and morbid obesity. Vaccination and early
treatment with antiviral medications are very important for HCP at higher risk for influenza
complications because they can decrease the risk of hospitalizations and deaths. HCP at higher
risk for complications should check with their healthcare provider if they become ill so that they
can receive early treatment.
The influenza vaccine has the potential to cause serious problems, such as severe allergic
reactions. The risk of the vaccine causing serious harm, or death, is extremely small. Serious
problems from influenza vaccine are very rare. The virus is inactivated, preventing transmission
of influenza from the vaccine.
 Mild reactions:
o soreness, redness, or swelling at the injection site
o fever
o aches
o If these problems occur, they usually begin soon after the shot and last 1-2 days
 Severe reactions:
o Life-threatening allergic reactions are very rare. If they do occur, it is usually within a
few minutes to a few hours after the injection.
o In 1976, a type of influenza (swine flu) vaccine was associated with Guillain-Barre
Syndrome (GBS). Since then, flu vaccines have not been clearly linked to GBS.
However, if there is a risk of GBS from current flu vaccines, it would be no more than 1
or 2 cases per million people vaccinated. This is much lower than the risk of severe
influenza, which can be prevented by vaccination.
Between October 1st and March 31st each year, the influenza vaccine is available all Agency
employees who have direct contact with patients.
If you have a medical condition, allergies, are pregnant or breastfeeding, please consult your
physician for direction prior to receiving the vaccine.
The Aspen Group
July 2012
3.16A