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Influenza Vaccination Declination Form

2. Napa Fire Department Influenza Vaccination Declination Form
   I understand that due to my occupational exposure to aerosol transmissible diseases (ATD), I may be at risk of acquiring Seasonal Influenza. I have been given the opportunity to be vaccinated against this disease or pathogen at no charge to me. However, I decline this vaccination at this time. I understand that by declining this vaccine, I continue to be at risk for acquiring seasonal influenza and complications from it. If, during the season for which the CDC recommends administration of the influenza vaccine, I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination at no charge to me.

   I understand that due to my occupational exposure to aerosol transmissible diseases (ATD), I may be at risk of acquiring Seasonal Influenza. I have been given the opportunity to be vaccinated against this disease or pathogen at no charge to me. However, I decline this vaccination at this time. I understand that by declining this vaccine, I continue to be at risk for acquiring seasonal influenza and complications from it. If, during the season for which the CDC recommends administration of the influenza vaccine, I continue to have occupational exposure to aerosol transmissible diseases and want to be vaccinated, I can receive the vaccination at no charge to me.

4. First Name*

5. Last Name*

6. Date*
   Date

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7. 1. Receive an email copy of this form.
8. Email address

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9. Submit

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