Flu declination form 2026

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3.9 out of 5

45 votes

The document is a declination form for influenza vaccination for the 2013/2014 season, provided by Student Health Services in Charleston, South Carolina. It allows students to formally decline the vaccine by indicating their reasons, such as religious beliefs or medical history, specifically citing Guillain-Barré Syndrome. The form requires student and healthcare provider signatures to certify the declination.

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Click ‘Get Form’ to open the flu declination form in the editor.
Begin by entering your last name, first name, and middle initial in the designated fields. Ensure that all personal information is accurate.
Fill in your birthdate and contact number. This information is essential for identification and communication purposes.
Review the Vaccine Information Sheet provided. Confirm your understanding by checking the box indicating you have read it.
Select the reasons for declining the influenza vaccine by checking all applicable boxes. Options include religious prohibitions or medical history concerns.
Sign and date the form in the designated areas to validate your declination request.
If applicable, have a licensed healthcare provider complete their section, including their signature and office details.

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What are the reasons for declination of flu vaccine?

Reasons for Refusing the Flu Vaccine I do not need the vaccination (17.3%) I might experience side effects or get sick from the vaccine (12.2%) I dont think the vaccination is effective in preventing flu (11.8%).

How do you write a flu declination letter?

I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, I have decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future.

How to get a religious exemption for a flu shot?

California removed its personal and religious exemption option in 2015. Parent/guradian must complete an online educational module to receive a non-medical exemption. Connecticut removed its religious exemption option in 2021.

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