Flu Vaccination

Vaccination Declination Form - Non-Employee


First Name:		Last Name
Male	Female	Date of Birth:
Work Location
Volunteer Student JLL Non-Employed Physician Private NP/PA Other
Physicians, Please enter your DR Number. (ex:DR1234)

	Check your reason for declining the influenza vaccine:
	I have medical reasons for not wanting the vaccine.
	I have religious reasons for not wanting the vaccine.
	I do not work in an area that requires the influenza vaccine and choose not to receive it.

	Please enter reason here.


	Non Employees who decline the influenza vaccination, must complete and submit the influenza vaccine medical exemption form completed by their personal medical physician. Click here to display the form. The documentation must be written by an M.D. or a D.O. and state the exact reason for the contraindication and submitted to OHS for approval. Non Employees who are requesting religious exemption, must provide documentation from the non employee's religious institution, signed by an official of the organization (It should be noted that almost all religions DO NOT prohibit vaccination) to OHS for approval. OHS is located at 550 Stephenson Hwy, Suite 200, Troy, MI 48083. Fax: 248-733-7301 Beaumont healthcare workers who decline the influenza vaccine will be encouraged to wear a surgical mask when providing direct patient care. By clicking the button below, I acknowledge that I will be expected to follow this best practice measure for reasons of patient safety.