87 Washington St Rensselaer NY 12144

Influenza Declination Form

First Name: Middle Initial: Last Name: Telephone #
Date of Birth: Age: Gender:
Address City: State: Zip Code

DECLINATION AND SIGNATURE

I DECLINE to be vaccinated against the influenza virus. I have had the opportunity to be vaccinated, but refused. I accept responsibility for my declination and risk of exposure. I agree to always wear a face mask provided to me by AccuCare Home Care while caring for my patient throughout the Flu season.

Employee Signature:
Draw your signature in the box above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

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