Infection 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

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