I understand that due to my occupational exposure to the influenza virus, I may be at risk of acquiring the influenza virus. I have also been asked if I have any questions regarding this information and if I had questions,they were fully answered to my satisfaction. I understand that my insurance coverage will cover the cost of the vaccine at no charge to myself.

I am declining the Influenza Vaccination for the following reason(s):

Must have NYS DOH 4482 form filled out by a physian, physian assistant, nurse practitioner nurse-midwife or licensed midwife. It can be found online at
http://www.health.ny.gov/ prevention/immunization/toolkits/docs/hospital_pg154.pdf

I decline the influenza vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring the influenza virus. If, in the future, while employed by Meadows Home Care CDPAP, I continue to have occupational exposure to the influenza virus and I want to be vaccinated with the vaccine, that my insurance will cover the cost at no charge to me. I understand thatI must wear a surgical mask at alltimes while providing care to my patient. I can obtain the mask at Meadows Home Care CDPAP Services free of charge.