Infection Prevention You are here:HomeFor Health ProfessionalsInfection Prevention Influenza Vaccination Response form Name* - required Email* - required Employee Number* - required Please participate in the 2019 Influenza Vaccination Campaign by responding: I would like to receive the influenza vaccine I have received the influenza vaccine elsewhere I would like to opt out of receiving the influenza vaccine If you chose to opt out in the above field, please state your reason: I think I will get influenza if I get the vaccine I don’t like needles I don’t wish to say I have an allergy or medical contraindication to receiving the vaccine My philosophical or religious beliefs prohibit vaccination refreshGet Audio Code Type the code from the image Mandatory field(s) marked with *