COVID Response



Influenza Vaccination Declination Form

I acknowledge I am aware of the following facts regarding influenza:

  • Influenza is a serious respiratory disease; on average, 36,000 Americans die every year from influenza-related causes;
  • Influenza virus may be shed for up to 24 hours before symptoms begin, increasing the risk of transmission to others;
  • Some people with influenza have no symptoms, increasing the risk of transmission to others;
  • Influenza virus changes often, making annual vaccination necessary;
  • I understand that the influenza vaccine cannot transmit influenza and it does not prevent all disease;
  • I acknowledge that influenza vaccination is recommended by the Centers for Disease Control and Prevention (CDC) for anyone over the age of 6 months in order to prevent infection from and transmission of influenza and its complications, including death, to my coworkers, my family and community;
  • I acknowledge that by declining the vaccine that I am more susceptible to the illness;
  • I understand that getting vaccinated myself may also protect people around me, including those who are more vulnerable to serious flu illness (i.e. infants, young children, older adults and individuals with certain chronic health conditions);
  • I understand the CDC recommends influenza vaccination, but in the context of the COVID-19 pandemic state it is even more important in order to reduce illnesses and preserve scarce health care resources; and
  • I understand that symptoms of influenza are similar to those of COVID-19 and therefore I may not be able to participate in academic and other activities in person in accordance with the Milligan Returns Home screening policy if I develop these symptoms due to the contraction of influenza.

Knowing these facts, I choose to decline vaccination at this time. I may change my mind and accept vaccination later, if the vaccine is available. I have read and fully understand the information on this declination form. I freely and voluntarily assume all risks of my decision to decline vaccination.

  • This information will be kept confidential in accordance with HIPAA and FERPA and will be used to assist in efforts vital to the safety and well-being of those on campus. Voluntary disclosure will have no implications for your enrollment or job status.
  • Date Format: MM slash DD slash YYYY

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