Sample Declination Forms
Examples of useful influenza vaccination declination forms are provided below for use in implementing a health care worker influenza vaccination campaigns.

Declination of Influenza Vaccination, NoFluForYou

Declination of Influenza Vaccination, Immunization Action Coalition

Refusal to Receive Vaccination, New York City Department of Health

2010-2011 Influenza Vaccine Declination Form, California General Acute Care Hospitals

Assessment of Annual Influenza Vaccination, Sutter Medical Center

Flu Vaccine Declination Statement 2010-2011, Columbia University Medical Center

Sample Letters/E-mails/Newsletters
Below are examples of sample letters, emails and newsletters that can be utilized in influenza vaccination promotion campaigns.

Protect Yourself and Your Patients (Newsletter), NoFluForYou

Education Information on Influenza Vaccination for Health Care Personnel (Newsletter), NoFluForYou

Facts About Influenza To Health Care Personnel and Patients, (Newsletter) NoFluForYou

Influenza Immunization Initiative Announcement (Newsletter), NoFluForYou

Influenza Vaccination Announcement (Newsletter), NoFluForYou

CEO Urging Influenza Immunization (E-mail), NoFluForYou

Announcing Influenza Clinic Dates and Times (E-mail), NoFluForYou

Letter for Management to Promote Immunization (Letter), NoFluForYou

Promotional Letter for Campaign Recruitment (Letter), NoFluForYou

Make Sure You’re Vaccinated (Newsletter), NoFluForYou

Policy Statement Template
Below is an example of an organizational policy statement relating to influenza vaccination mandates.

Template Policy Statement for Influenza Immunization of Health Care Personnel (HCP),
Michigan Department of Community Health, Adopted from the Association for Professionals
in Infection Control & Epidemiology (APIC)

Sample Checklists
The following are examples of checklists that can be used in the implementation of an influenza vaccination campaign for health care personnel.

Promoting Seasonal Flu Vaccination: A Checklist for Businesses and Employers, Centers for Disease Control and Prevention (CDC)

Suggestions to Improve Your Immunization Services, Immunization Action Coalition

Sample Screening Forms
The following are examples of screening forms that can be used in the implementation of an influenza vaccination campaign for health care personnel.

Screening Questionnaire for Live Attenuated Intranasal Influenza Vaccination,
Immunization Action Coalition

Screening Questionnaire for Seasonal and H1N1 Influenza Injectable Vaccination,
Adapted by the Massachusetts Department of Public Health from the Immunization Action Coalition

Screening questionnaire for H1N1,
Amherst, Massachusetts Health Department

Other Forms
The following are examples of other forms that can be used in the implementation of an influenza vaccination campaign for health care personnel.

Checklist for Safe Vaccine Storage and Handling, Immunization Action Coalition

Immunization Consent and History, Missouri Department of Health and Senior Services

Influenza Toolkit Evaluation Form, NoFluForYou

Influenza Vaccination Declination Tracking Roster, NoFluForYou

Influenza Vaccine Availability Tracking System (IVATS), Prevent Influenza, 2011 at the organization

Vaccine Administration Record For Adults, Michigan Department of Community Health

Vaccine Adverse Event Reporting (VAERS) Form, US Department of Health and Human Services

Vaccine Guide to Contraindications and Precautions to Commonly Used Vaccines, Immunization Action Coalition

Vaccine Management Guidelines, Missouri Department of Health and Senior Services

Campaign Communication Samples
The following are examples of campaign communication samples that can be used in the implementation of an influenza vaccination campaign for health care personnel.

Flu Fact Talking Points, NoFluForYou

Talking Guidelines for Managers to Encourage Vaccination of Health Care Personnel, NoFluForYou

Talking Points for Managers to Promote Influenza Vaccination Campaign, NoFluForYou

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