SJHS - Bardstown - 2011 Influenza Vaccination Employee Profile - (copy) - (copy)

Saint Joseph Health System is preparing for a new requirement to monitor the influenza vaccine status of all employees. Please complete the survey to help our organization promote your health, protect patients, and meet this new requirement. Thank you.
Name: 


A red asterisk (*) indicates required questions.

  1. I commit to receive the influenza vaccine free of charge through SJHS? *
    Yes
    No


  1. I have received the vaccine at another location. (Please provide a copy of the consent form to your manager).*
    Yes
    No


  1. I decline to receive the influenza vaccine because of a medical condition. Please contact your Employee Health Nurse for a confidential consultation. Please specify conditions:
    I have a severe egg or chicken protein allergy
    I have had a life threatening allergic reaction to a previous seasonal influenza vaccination
    I have had a severe allergy to any other vaccines
    I have a history of Guillain-Barre Syndrome
    I am currently ill with fever, cough, etc.
    I am allergic to thimersol
    I have a hypersensitivity to neomycin or polymyxin
    I have asthma
    I have diabetes
    I have kidney disease
    I have an airway disease
    I have heart problems
    I have breathing problems
    I have anemia
    I have a blood disorder


  1. I decline to receive the influenza vaccine for other reasons. Please explain:





Rose Patrick
Lexington, KY