Community Immunity - 2016 Staff Influenza Vaccination -Report your status form

Complete the form below if you have had the influenza vaccination elsewhere (external to Alfred Health), or wish to decline the influenza vaccine

OR to arrange a vaccination contact the staff immunisation clinic on 9076 3323.

Thank you

PLEASE NOTE: If you close the browser session prior to submitting your completed survey, an incomplete survey will be submitted. You will need to complete and submit another survey to ensure that your influenza status is updated.

Employee Number (if known)

First name

* must provide value

Last name

* must provide value

Date of Birth (D-M-Y)

* must provide value

D-M-Y

Contact Number

Who is your MAIN employer? (Select ONE only)

* must provide value

Other (please specify)

* must provide value

Ward

Department

Campus/other

(One selection allowed per column)

I have received the 2016 Influenza vaccine ELSEWHERE (external to Alfred Health)

I DECLINE the 2016 Influenza vaccine through Alfred Health

2016 Influenza vaccine

* must provide value

reset

I understand that I may change my mind at any time and accept the influenza vaccine if it is still available.

The reason I have chosen to to decline this year's influenza vaccine is because (please select):

* must provide value

Known medical contraindication

Needle phobic

Not at risk of the flu

The flu vaccine doesn't work

Flu is not a serious illness

The flu vaccine makes me sick

Other

Please specify

* must provide value

I have already received the 2016 Influenza Vaccine ELSEWHERE (external to Alfred Health).
I declare that I have received the 2016 Influenza vaccine through the following identified health service provider.

* must provide value

Please specify name and location

* must provide value

Signature
I declare the details I have supplied are correct.

* must provide value

Add signature

Date of signature

* must provide value

D-M-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.