Employee Health,Safety,Organizational Services,

Clinical Hub,Patient Safety,Influenza Vaccination and TB Screening,Resources

2017-2018 Seasonal Influenza Vaccine Medical Waiver

2017-2018 Seasonal Influenza Vaccine Medical Waiver - Clinical Hub, Patient Safety, Influenza Vaccination and TB Screening, Resources

I decline the influenza vaccine due to medical reasons.
I attest the information provided on this waiver is true to the best of my knowledge. I understand that I am
encouraged to wear a mask when working in a patient care area within three (3) feet of a patient when there is the
presence of influenza in the community as defined by the Hospital Epidemiologist.
Name: ID #: DOB:
Status: Employee/Faculty Volunteer Student Non-employee
Employee signature: Date: ____
Medical Waiver - I, (print provider name), certify that the above
named person is under my medical care and should be exempt from receiving the influenza vaccination due to medical
reason(s) noted below:
Recognized contraindication to influenza vaccination (please mark all that apply and include dates of reaction, if
Severe allergic reaction to eggs. Date of reaction:
• Defined as developing hives, swelling of the lips or tongue, difficulty breathing.
• Does not generally result in only gastrointestinal symptoms.
• The amount of egg protein in influenza vaccines is extremely small. People who can tolerate eating lightly
cooked egg, such as scrambled egg, can generally tolerate the influenza vaccine.
History of previous severe allergic reaction to the influenza vaccine or component of the vaccine
Date of reaction:
• Defined as developing hives, swelling of the lips or tongue, difficulty breathing.
• Does not include sore arm, local reaction or subsequent upper respiratory tract infection.
History of Guillain-Barre syndrome within six (6) weeks of receiving a previous vaccine.
Date of reaction:
Other medical contraindication; please describe in space below (these requests will be reviewed on a case-by-case

Long-term medical waiver ( >1 year) Short-term medical waiver (limited to 2017 – 2018 flu season)

Provider Name (please print) Provider signature

Date signed Provider phone number

Long-term medical waivers do not need to be completed annually. However, if you choose to receive a flu vaccine after completing
a medical waiver, you will need provider documentation that the vaccine is safe for you. If you have a short-term medical waiver
for 2017 – 2018 flu season, a waiver would need to be resubmitted next year if medically necessary.
Please return completed waiver to the appropriate department below:

Revised 08/2017
UWHC or UWMF: Employee Health Services
700 University Bay Drive, Suite 101
Madison, WI 53705
Interdepartmental Mail Code: 6715
Fax: 608-262-7284
Scan/email to: hremployeehealth@uwhealth.org

UWSMPH: Dean’s Office Human Resources,
Health Sciences Learning Center, Room 4146
750 Highland Avenue, Madison, WI 53705
Fax: 608-262-9515
Scan/email: SMPHFlu@med.wisc.edu