Kaiser permanente flu shot form signed 2026

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4.1 out of 5

48 votes

The document is an Influenza Vaccine Form for the 2016-2017 season, intended for employees in Northern California. It includes sections for employees to indicate whether they received the flu vaccine, decline it, and acknowledge the risks associated with influenza. Employees who refuse vaccination are informed about the necessity of wearing a mask during patient care under certain conditions. The form also allows individuals to specify their reasons for declining the vaccine.

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Click ‘Get Form’ to open the kaiser permanente flu shot form in the editor.
Begin by entering your personal information in the designated fields: Name, Department, Medical Record #, and Employee Number #.
Indicate whether you received the 2016-2017 Flu Vaccine by checking the appropriate box for Injection or Nasal spray. Provide the approximate date of vaccination if available.
If you choose not to receive the vaccine, check the box indicating your decision and read through the acknowledgment statements regarding influenza risks.
Select your reason for declining vaccination by checking all applicable boxes under 'I decline vaccination for the following reason(s)'.
Sign and date the form at the bottom to confirm your choices and understanding of the information provided.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (171 Votes)
2016	4.1 Satisfied (48 Votes)

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