SJH - Bardstown - 2012 Influenza Vaccination Employee Profile

Kentucky One Health 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.*
    Yes
    No


  1. I have received the vaccine at another location. (Please provide a copy of the consent form to your manager/employee health).*
    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 have a hypersensitivity to neomycin or polymyxin
    I am allergic to thimersol


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





Rose Patrick
Lexington, KY