ANR Employees
University of California
ANR Employees

Declination of Influenza Vaccine

Declination of Influenza Vaccine

Declination of Influenza Vaccination

The University of California recommends that all members of the community, except those who have medical contraindications, receive a vaccination to protect against influenza (flu) during the 2021-2022 flu season. I understand that:


  1. According to the Centers for Disease Control & Prevention (CDC), vaccination against the seasonal respiratory disease influenza or “flu” has long been accepted as a safe and effective way to prevent millions of illnesses and thousands of related doctor and hospital visits every year. Flu vaccination in adults substantially reduces the risk of severe illness. By getting vaccinated, a person can also protect those around them, including those who are more vulnerable to serious flu illness.


  1. The CDC’s Advisory Committee on Immunization Practices (ACIP) has issued recommendations regarding influenza vaccination for the 2021-2022 season. Specifically, ACIP advises that the “2021-22 influenza season is expected to coincide with continued circulation of SARS-CoV-2, the virus that causes COVID-19. Influenza vaccination of persons aged ? 6 months to reduce prevalence of illness caused by influenza will reduce symptoms that might be confused with those of COVID-19. Prevention of and reduction in the severity of influenza illness and reduction of outpatient visits, hospitalizations, and intensive care unit admissions through influenza vaccination also could alleviate stress on the U.S. health care system.”


  1. During the SARS-CoV-2 pandemic, where COVID-19, like influenza, results in respiratory symptoms, it is even more critical than usual to assure widespread vaccination. As California has lifted COVID-19 restrictions, outbreaks have followed and the possibility of a surge that overwhelms the health care system and causes hospitals to adopt crisis standards of care necessarily increases. Population-level interventions that decrease the likelihood of absenteeism, disease transmission, hospitalization, and ICU utilization must therefore be considered and adopted where feasible.


  1. By signing this form, I acknowledge that:
    1. I have read and understand the information provided in this informed refusal.
    2. I have had the full opportunity to ask questions concerning the vaccine and have received satisfactory answers to my questions.
    3. DO NOT agree to have the vaccine as recommended.
  2. [OPTIONAL] I am choosing to decline the flu vaccine for the following reasons (check all that apply, or that you prefer not to answer):

   Medical Contraindication or Disability

   Religious Belief

   Personal Belief


   Prefer Not to Answer

I understand that I can change my mind at any time and accept the flu vaccine.

I understand that as long as I refuse to accept the flu vaccine, I may be required to take extra precautions against transmission while at work, consistent with local policies.


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If Interpreted:                                                                                                              Date                                                                                 

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Printable Copy of the Influenza Vaccine Declination Form 2021

If you decide to decline receiving the Flu Vaccine, please complete the Vaccination Status Disclosure. 

* RETURN TO David Ritz, *

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