Get Ca Kaiser Permanente Influenza Vaccination Declination Form 2021-2025

This guide provides detailed instructions on how to complete the CA Kaiser Permanente Influenza Vaccination Declination Form online. By following these steps, users can efficiently navigate the form and ensure all necessary information is provided accurately.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred online editor.
2. Begin by indicating if you received the 2021-2022 flu vaccine by filling in your name, department, phone number, medical record number, person ID, location, and date.
3. If you choose not to receive the flu vaccine, check the box stating 'I DO NOT WANT THE FLU VACCINE' and read the provided information regarding the vaccine and its importance.
4. Acknowledge your decision to decline the vaccination by confirming your awareness of the risks associated with influenza by reading the declaration.
5. Select your reason for declining the vaccine by checking all applicable boxes (A, B, C, or D) and providing additional information if necessary for option D.
6. Affirm your understanding of the risks associated with declining vaccination and that you have had the opportunity to receive the vaccine without charge.
7. Provide your signature and the date signed in the designated fields to finalize your declination.
8. After completing the form, you have the option to save changes, download, print, or share the form as needed.

Complete the CA Kaiser Permanente Influenza Vaccination Declination Form online today!