Get Flu Declination Form - Extranet - University Of Rochester

Filling out the Flu Declination Form is an essential process for indicating your decision regarding the influenza vaccination. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete the Flu Declination Form.

1. Press the ‘Get Form’ button to retrieve the Flu Declination Form. Once obtained, it will open for you to fill out online.
2. In Section I, indicate if you have received the flu vaccine elsewhere by providing the date you received it and your signature. Ensure to include your date of birth and job title. Remember to include details on where the vaccination was administered, such as your primary care physician or a community program.
3. In Section II, state if you have a medical contraindication by confirming that your physician has advised against receiving the vaccine. Provide your signature, employee ID, and job title. If applicable, fax your physician's statement regarding the contraindication to the designated office.
4. In Section III, articulate your reasons for declining the influenza vaccine. Indicate the reason(s) from the provided options, such as personal beliefs or concerns about side effects. Include your name, date of birth, department, job title, signature, and date.
5. After completing all sections, review your information for accuracy. You can then save the changes made to the form, download a copy for your records, print it if needed, or share it with the relevant department.

Complete your Flu Declination Form online today for a smooth process.