Influenza Vaccine Waiver/Declination

Craft Health
1650 38th Street, Suite 101E, Boulder, CO 80301
720-274-5974

Please complete ONLY ONE of the reasons below – either the Waiver or Declination – and NOT BOTH

Influenza vaccine is STRONGLY RECOMMENDED FOR HEALTHCARE WORKERS, not only to protect themselves, but to reduce the chance of spreading influenza to our patients and community. Influenza infection can lead to serious complications and can be fatal, especially in elderly or sick persons. When infection occurs despite vaccination, it is usually milder. Craft Health is committed to the health and well-being of our employees, employee’s families and patients, and considers influenza vaccination of all Craft Health employees a high PATIENT SAFETY priority.

Waiver – complete if not eligible to receive vaccine

I am not eligible to receive the influenza vaccine today due to medical contradiction. I understand that I will be required to wear a surgical mask while performing assigned duties for patients in a facility or private home for the duration of the respiratory virus season, which is considered October through April. I understand by typing my name below and clicking on "Submit," I am electronically signing this document.

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Declination

I am eligible to receive the influenza vaccine, BUT DO NOT WANT to take it. I understand that by refusing the vaccine I may be putting my SELF, CRAFT HEALTH STAFF, and PATIENTS at risk of getting influenza. I am declining receipt of flu vaccine based on reasons of conscience, including religious beliefs. I understand that I will be required to wear a surgical mask while performing assigned duties for patients in a facility or private home for the duration of the respiratory virus season, which is considered October through April. I understand by typing my name below and clicking on "Submit," I am electronically signing this document.

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