Influenza Vaccination Status - volunteer annual ed.

INFLUENZA VACCINATION STATUS FORM

I, blanks* (print name) have been informed that in accordance with New York State regulation all healthcare personnel are required to provide influenza vaccination status.
The standard of care in New York State is that all health care personnel should receive an annual influenza vaccination. Health care personnel who choose not to be vaccinated must wear a surgical mask while in designated patient areas during officially declared influenza prevalence.
The NYS Commissioner of Health declares when influenza is prevalent and when that ends. This information will be relayed to employees by Hospicare.

Check the box that applies to you:*

I have received, or plan to receive, the vaccination and will provide Hospicare with the official paperwork when I have received the vaccination. (If the Commissioner of Health has declared that influenza season is prevalent before I receive it, I agree to wear a surgical mask when in designated patient areas, until I receive it and provide Hospicare with the appropriate documentation.)I am refusing to receive the Influenza vaccination all together and agree to the above terms requiring me to wear a surgical mask.

By checking this box and signing my name below I am electronically signing this form.

Employee Signature*

Date*

Date