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At SARA Companion HomeCare Services, we want all our caregivers to be healthy which is one reason we encourage them to get an annual flu shot.

However, we do understand that there are reasons why some caregivers bypass this annual way to protect themselves from the flu.

For this reason we have a flu vaccine waiver or declination of Influenza Vaccination form that a caregiver may fill in and submit to the agency.

Please fill in the form for the Flu Vaccine Waiver below.

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My employer SARA Companion HomeCare Services Inc. has recommended that I receive the influenza vaccine to protect myself and the patients that I care for.
I acknowledge that I am aware of the following facts.
1. Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
2. The influenza vaccine is recommended for me and all other healthcare workers to protect patients from influenza, its complications and death.
3. If I contract influenza symptoms may not appear until about 24 hours and during that time, I may spread influenza to others.
4. If I become infected with influenza, I can spread the virus even if my symptoms are mild or non-existent.
5. I understand that there may be various strains of the virus from year to year and my immunity may decline overtime. To prevent possible exposure, it is recommended that I receive the influenza vaccine on an annual basis.
6. I understand that I can't get influenza from the vaccine.
If I decline the influenza vaccine there could be life threatening consequences to my health and individuals that I come in contact with listed below. ~All patients in my care, my co-workers, my family, and my community
I understand that I can change my mind at any time and receive the influenza vaccine. Until then, I agree to wear a mask during my shift(s).
I have read and fully understand the information in this Declination form.
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