Flu declination form 2026

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The document is a Seasonal Influenza Attestation/Declination Form from Broward Health, emphasizing the importance of annual influenza vaccination for healthcare workers to protect themselves and patients. It outlines the risks associated with influenza, the benefits of vaccination, and the consequences of declining the vaccine. The form allows students to either document their vaccination or formally decline it while acknowledging their understanding of the related health implications.

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Click ‘Get Form’ to open the flu declination form in the editor.
Begin by filling in your school or company name and program details at the top of the form. This ensures that your submission is properly attributed.
Next, enter your rotation dates, title, and full name. Make sure to include the last four digits of your Social Security Number for identification purposes.
Indicate the date you received the influenza vaccine if applicable. If you are declining, proceed to sign the section acknowledging your understanding of the information provided.
If you choose to decline the vaccine, ensure you sign and date the appropriate section confirming your decision and understanding of its implications.

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