CPNW

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Requirement Name

Influenza Vaccine

Abbr.

IIV

Required By

All

Frequency

Annually

Instructions

An seasonal flu vaccine is required. It must be completed October 1st of each year. If you do not wish to get a seasonal flu shot, you must state your reason and submit a declination form. You must sign and submit a declination form for each facility where you will complete a clinical experience. Note, some facilities may refuse to place individuals who have declined.

Declination Forms

CHI-FH Declination
MHS Declination
Swedish Declination

Declination Form
Declination Form
Declination Form

Submission:

Immunization Date

Location Received

Declination Reason Egg Allergy Ingredient Allergy Guillain Barre Other

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Do not allow file submission in this category without expiration date and at least one attachment on each requirement.

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Name

Some Immunization

Abbr

XXXX

Required By

All

Frequency

Once

Immunization Date:

Expiration:

Documentation

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Flu Shot Custom Form

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Submission:

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