Influenza/Flu Vaccinination Refusal

New York State Department of Health requires that our agency document the Influenza vaccination status of our home care workers. All home care workers must submit the Influenza Vaccination documentation or Refusal Statement to our agency. It is Not Mandatory to be vaccinated. It is recommended that unvaccinated personnel wear a surgical mask at all times while in the area where client(s) may be present during influenza season.

    By signing below, I acknowledge that I have received influenza vaccine information; I choose not to receive influenza vaccine. I agree to wear a surgical mask at all time while in area where clients may be present during Influenza season.


    Scroll to Top