/infohub/vaccine-exemption-form

Shields Health
2024-2025

INFLUENZA & COVID-19 VACCINE EXEMPTION FORM

Vaccination Benefits, Risks and Recommendations

Please read the following. The form can be found below the information.

Influenza Vaccination:

Additional up to date detail can be found through the CDC

- Flu vaccination has been shown in several studies to reduce severity of illness in people who get vaccinated but still get sick.
- Flu vaccination can reduce the risk of flu-associated hospitalization.
- Everyone 6 months of age and older is recommended to get an annual flu vaccine, including even healthy adults.
- Vaccination to prevent flu is especially important for people at higher risk of serious influenza complications or people who live with or care for people at higher risk for serious influenza complications.
- The strains of virus that cause influenza infection change almost every year, and, even if they don't change, immunity declines over time. This is why vaccination against influenza is recommended every year.
- Common side effects from a flu vaccine include soreness, redness, and/or swelling where the shot was given, headache (low grade), fever, nausea, muscle aches, and fatigue. The flu shot, like other injections, can occasionally cause fainting.

COVID-19:

Additional up to date detail can be found through the CDC

- Prevents serious illness: vaccines available in the United States are safe and effective at protecting people from getting seriously ill, being hospitalize, and dying.
- Getting a COVID-19 vaccine is a safer, more reliable way to build protection than getting sick with COVID-19.
- COVID-19 vaccines can offer added protection to people who had COVID-19, including protection against being hospitalized from a new infection.
- COVID-19 vaccines are highly effective in preventing the most severe outcomes from a COVID-19 infection.
- Vaccine protection decreases over time, so it is important to stay up to date with your COVID-19 vaccine.
- Some people have side effects after COVID-19 vaccination, while others might have not side effects. Side effects tend to be mild, such as soreness at the injection site and fever, and should go away within a few days.

Reference: Centers for Disease Control and Prevention (CDC) COVID-19 https://www.cdc.gov/covid/vaccines/stay-up-to-date.html | Influenza https://www.cdc.gov/flu/prevent/flushot.htm

Shields Health 2024-2025

INFLUENZA & COVID-19 VACCINE EXEMPTION FORM

Name *

First

Last

Date of Birth *

Email *

Department/Position *

Manager's Name *

I have received information about the vaccine’s benefits, risks and recommendations from the CDC specific to Covid-19 and Influenza, and I have declined the offer for the following vaccination(s): *

Influenza (Flu)
COVID-19

Signature *

Clear Signature

l acknowledge that my employer, Shields Health, follows DPH and CDC requirements which recommend that I receive the influenza and COVID-19 vaccination to protect myself, patients, staff and others in the healthcare facility. I have received information about the vaccine's benefits, risks and the recommendations from the Centers for Disease Control and Prevention (CDC) specific to COVID-19 and Influenza. I understand that vaccination is a recommended preventive measure against influenza and COVID-19 and it may help protect me and others from disease. Despite the recommendations and information provided, I choose not to receive the vaccination(s) at this time. By electronically signing this form, I acknowledge and agree that my electronic signature has the same legal validity and effect as a handwritten signature. I confirm that I have read and fully understand the contents of this document, including the risks of declining the influenza (flu) and/or COVID-19 vaccines, and I voluntarily choose to decline vaccination at this time.

Date *