KYOne Health West - 2013 Influenza Vaccination Employee Profile

Kentucky One Health isrequired by many governing bodies to have an influenza program that educates, offers the vaccine, and tracks those who decline the vaccination annually. KentuclyOne Health strongly encourages everyone to receive the influenza vaccine in order to protect ourselves, our patients, our workforce, and our community.
Name: 


A red asterisk (*) indicates required questions.

  1. I will take the influenza vaccine when it is offered*
    Yes
    No


  1. Despite the facts presented to me in this LEARN module, I am choosing to DECLINE the influenza vaccination.*
    Yes
    No


  1. I understand by declining this vaccine I must include reasoning for the declination. Please choose one of the reasons below:*
    Not Applicable: I will take the influenza vaccine when it is offered
    I have an allergy to the influenza vaccine
    I have never taken the inluenza vaccine before
    I do not want the influenza vaccine
    I never get the flu
    I get sick when I take the influenza vaccine


  1. I decline to receive the influenza vaccine because I have received at a facility other than KentuckyOne Health (You are required to submitt this documentation to your local Employee Health Office by December 31, 2013 for compliance.*
    Not Applicable: I will take the influenza vaccine when it is offered
    Yes
    No


  1. I decline the influenza vaccine for other reasons, Please Explain:





Rose Patrick
Lexington, KY