Get Influenza Vaccine Acceptance/declination Form - Environment ... - Www-ehs Ucsd

Filling out the Influenza Vaccine Acceptance/Declination Form is essential for individuals exposed to the influenza virus in their work environment. This guide provides a clear, step-by-step approach to successfully complete the form, ensuring your choices regarding vaccination are well-documented.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the Influenza Vaccine Acceptance/Declination Form. This will allow you to obtain the form and open it in a digital editor.
2. Review the information regarding influenza risks and the benefits of vaccination provided in the introductory section of the form. Make sure you understand the importance of the vaccine in relation to your occupational exposure.
3. Choose one of the two options presented on the form regarding your participation in the vaccination program. You must select either the acceptance of vaccination or the declination of vaccination.
4. If you accept the vaccination, make a note to request an appointment for vaccination at the UCSD Center for Occupational and Environmental Medicine (COEM). Ensure you have your employer's authorization if required.
5. If you decline the vaccination, acknowledge your understanding of the continued risk of influenza and fill out the date of your most recent influenza vaccination if applicable. Provide any necessary documentation to the EHS Occupational Health Nurse.
6. Complete the personal information section by providing your name, phone number, UCSD employee ID, email address, department name, and recharge index number for tracking purposes.
7. Indicate your participant status by checking the relevant boxes that apply to you among the options listed.
8. Sign and date the form to confirm your choices and understanding. This step is vital to validate the form.
9. Submit the completed form by returning it to the Occupational Health Nurse via fax or mail, using the contact information included on the form.

Complete your Influenza Vaccine Acceptance/Declination Form online to ensure your vaccination status is accurately recorded.