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Influenza vaccine exemption form

Download a printable PDF version of the flu shot exemption form here

The University of Dayton has initiated an influenza vaccination program for fall 2020, to reduce the risk of potentially severe respiratory illness during this academic year.  Each year in the United States, influenza kills thousands of people and causes hundreds of thousands of hospitalizations.  Influenza vaccination is recommended* to help protect everyone on campus from influenza, its complications, and death.  In fall 2020, it is especially prudent to reduce the presence of illnesses with respiratory impacts, because individuals with COVID-19 may exhibit similar symptoms (such that anyone with such symptoms should avoid others and stay home).  And for a community such as the University of Dayton, where many individuals live or work in congregate settings, it is advisable to reduce the potential for illness so that our community is able to continue to live and work together on campus.  Against such a backdrop, public health officials and the University’s medical advisory panel have recommended the influenza vaccine for everyone in the campus community.

As a member of the University community, I understand that, if I contract influenza, I can shed the virus for 24 hours before any influenza symptoms appear.  If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread influenza to others. Symptoms that are mild or non-existent in me can cause serious illness and death in others.  I understand that the strains of virus that cause influenza infection change almost every year and, even if they do not change, my immunity declines over time.  This is why vaccination against influenza is recommended every year.  I understand that it is impossible to get influenza from influenza vaccine.  My refusal to be vaccinated could have life-threatening consequences for my health and the health of everyone with whom I have contact.

Despite these facts and considerations, I am choosing to decline influenza vaccination for the following reason(s):

⃞   Religious 

⃞   Medical, specifically ____________________________________________________

⃞   Philosophical

⃞   I am not planning to be on campus during the entirety of the 2020-21 academic year

I understand that I can change my mind at any time and decide to accept influenza vaccination at a later date.  I understand the risks of non-immunization and hold the University of Dayton harmless from any responsibility for adverse consequences of my refusal to be immunized against influenza.

I have read and fully understand the information on this exemption form.

Signature ___________________________________________________ Date ___________________

Name (print) _________________________________  UD ID # (first 9 digits) __________________

Check one:        ⃞  Faculty       ⃞  Staff       ⃞  Student

Please email the completed form to