Medical Exemption Request Form for Influenza Vaccination
Legal Name: ___________________________________
Date of Birth or Employee ID#: ____________________
Work number: _________________________________
Personal phone#: _______________________________
Home address: _________________________________
Email: ________________________________________
Facility: ____________________________________
Employee unit/department: ____________________________________
Shift: __Days __Nights
Personal Physician Name: _________________________________
Physician Phone Number: ____________________
Please answer the following questions to help us understand the reasons for requesting a Medical Exemption to the flu vaccine:
- Have you had a flu vaccine before? __Yes __No
- If yes, did you receive a flu vaccine injection or mist? __Injection __Mist
- If you have had the flu vaccine when was the last time you were vaccinated to the best of your recollection?
Year of last influenza vaccination: ______________________________
- Do you have an egg allergy? __Yes __No (if no, skip to question 7)
If yes, check all of the following conditions that you experienced
__I don’t eat eggs or egg products
__Severe allergic reaction from eggs/egg products
__Tongue Swelling
__Nausea/vomiting
__Rash and or hives
__Respiratory difficulty
__Other _______________________________________________________________
- Was your reaction severe enough to seek medical attention? __Yes __No
Employee Name:______________________________
- If yes, where was your reaction treated? (check all that apply)
__Home
__Physician office
__Emergency room
__Urgent Care
__Hospital
- Do you have an allergy to components of the vaccine or other adverse reaction to flu vaccine? Yes___ No___
a. If yes, identify component of vaccine that you are allergic to:
__Component unknown
__Other: ______________________________________
- If yes, check all the following conditions that you experienced
__Anaphylactic reaction
__Tongue Swelling
__Rash and or hives
__Pain, redness or swelling at injection site
__Decreased range of motion in arm
__Fever
__Respiratory difficulty
__Nausea/vomiting
__Serum Sickness
__Flu like illness that left you unable to work (describe symptoms and duration____________________
__Allergies to other medications (list medication)____________________
__Headache/migraine
__Guillain-Barre’ Syndrome (a severe paralytic syndrome) within 6 weeks of vaccination
__Other: _______________________________________________________________
- Was your reaction severe enough to seek medical attention? __Yes __No
Employee Name: ________________________
- If yes, where was your reaction treated? (check all that apply)
__Home
__Physician office
__Emergency room
__Urgent Care
__Hospital
- Is there any another reason you feel you should receive a medical exemption from the flu vaccine? Please explain with as much detail as possible to the specific symptoms / concerns you have._______________________________________________________________
I will be submitting additional information to Employee Health Services by fax? __Yes __No
I authorize Union Hospital, Inc. to contact the physician listed above to clarify the medical reason(s) I have given for not wanting to take the influenza vaccine. Additionally, I understand that once the physician listed above has provided this information, it can be used to assist the Union Hospital, Inc. influenza Medical Exemption Committee in making their decision to approve or deny my exemption request, and this information may be kept in my confidential Employee Health file. I may request a copy of my signed authorization if desired. I understand that I may revoke this authorization at any time unless this authorization has already been carried out and your physician has provided the information requested. This authorization will expire when I am no longer employed by Union Hospital, Inc. or any of its affiliated entities if I do not cancel it in writing prior to the expiration date. I understand that if I want to cancel/revoke this authorization, I must mail, fax, or bring a letter in person to the Employee Health Department where I received the influenza vaccination stating that I want to cancel this authorization.
Employee Signature: __________________________________________Date: ______________
Medical Provider Signature: ____________________________________Date: ______________
Internal Use Only:
[ ] Exemption approved [ ] Exemption Denied [ ] Further clarification needed
If approved:
[ ] Temporary Exemption (for this year only) [ ] Permanent Exemption
Employee Name: ________________________
Clarification needed:
[ ] Employee requested to provide supporting documentation
[ ] Personal physician contacted for further clarification
Date notification sent to employee: _____________________
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Flu Exemption Committee Representative Signature:__________________________________
Submit to the Employee Health Department or Fax to Employee Health at 812-238-7287. Thank you.
