I have been advised by Rockaway Home Care that I should receive the influenza vaccine to protect myself and the patients I serve. I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have had the opportunity to discuss the statement and have my questions answered by a healthcare provider. I am aware of the following facts:
I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, I have decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future.
260 Doughty Boulevard, Inwood, NY 11096
526 Beach 20th St., Far Rockaway, NY 11691