Influenza (Flu) Vaccine Declination

Aultman requires staff, students and volunteers to receive an annual influenza vaccine or wear a mask upon entry to areas where healthcare is provided or solicited. The mask usage requirement will remain in effect until the defined end of the influenza season.

**COVID restrictions supersede Influenza restrictions**

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Email
What student experience are you partaking in?

What student experience are you partaking in? Clinicals Internship Observation
What school do you attend?

If you're a non-student doing an observation put N/A.
What program are you in?

“I’m in the Stark State LPN Clinical Group” or “I’m interning in Anesthesia”, etc.
Start Date Start Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
I am choosing not to be vaccinated due to the following reasons and will wear a mask while in defined patient care areas where healthcare is provided or solicited.

I am choosing not to be vaccinated due to the following reasons and will wear a mask while in defined patient care areas where healthcare is provided or solicited. I have a severe allergy to eggs I am allergic to components of this vaccine I have a medical conditions or history of Guillain-Barre Syndrome that prevents me from recieving the vaccine I don't receive vaccines for religious reasons Other Other
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