<p> Influenza Vaccination Declination Tracking Roster PLEASE NOTE: For patient confidentiality purposes, the Employee Health Department is the only Department that should keep and maintain this declination roster. The Employee Health Department is responsible for monitoring all employees and/or contractors who decline to receive flu vaccination.</p><p>DATE LAST NAME FIRST NAME EMPLOYEE UNIT /DEPARTMENT * **Reason for NUMBER Yes declination See codes below Example Doe Jane 148540 Infection X 9. Allergy 10/15/05 control</p><p>* YES Employee/Contractor has been provided with information about the risks and benefits of influenza vaccination but has declined for reasons selected below. **Declination Codes 1. Do not believe in vaccines for religious or philosophical reasons. 2. Concerned about side effects/safety 3. Believe the influenza vaccine gives a person the flu. Employee Health Staff 4. Do not believe the vaccine prevents the flu. (Print legibly) 5. Do not believe its important – “I never get the flu” Phone 6. Inconvenient 7. Received influenza vaccine elsewhere (provide documentation) 8. I don’t like needles. 9. Other (see employee file)</p><p>Adapted From The Massachusetts Medical Society revised 3/07 lg</p>