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2017–2018 Influenza Vaccine Religious Belief Or Personal Conviction Waiver

2017–2018 Influenza Vaccine Religious Belief Or Personal Conviction Waiver - Departments & Programs, UW Health, Employee Health Services, Influenza Vaccination and TB Screening, Resources


Studies have shown the importance of vaccinating every health care worker in a healthcare institution to
protect patients, their families, and co-workers. Every increase in vaccination level leads to greater
protection for all. Vaccination of health care employees serves several purposes: (1) to prevent
transmission to patients, including those with a lower likelihood of vaccination response themselves; (2) to
reduce the risk that the employee will become infected with influenza; (3) to create “herd immunity” that
protects both employees and patients who are unable to receive vaccine or unlikely to respond with a
sufficient antibody response; (4) to maintain a critical societal workforce during disease outbreaks; and (5)
to set an example concerning the importance of vaccination for every person.

All UW Health employees will contribute to the protection of our patients, their families, and each other by
being immunized on an annual basis unless that employee submits a valid request for a waiver.
Employees requesting waivers are reminded that they are highly encouraged to mask whenever they are
within three feet of a patient when there is the presence of influenza in the community as defined by the
Hospital Epidemiologist.

A religious belief or personal conviction waiver is allowed for those holding a system of sincerely and
deeply held traditional, non-traditional or unique religious beliefs, unique personal convictions of a moral
or ethical nature as to what is right and wrong, or a personal belief based on other reasons not indicated

I , have read the definition of a valid waiver above and attest the
information provided on this waiver is valid and true to the best of my knowledge, and I further certify that:

I decline the influenza vaccine due to my sincerely and deeply held religious beliefs; or

I decline the influenza vaccine due to my sincerely and deeply held personal convictions/beliefs.

Name ID # DOB:


Status: Employee/Faculty Volunteer Student Non-employee

Employee signature Date

Religious or personal conviction/belief waivers do not need to be completed annually unless a new policy
or waiver form is implemented. However, if you choose to receive a flu vaccine after completing a waiver,
you will need to complete a new waiver if you ever want to waive the vaccine in the future.

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 to: SMPHFlu@med.wisc.edu