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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Influenza Vaccination
Policy Number: 9.75
Effective Date: October 1, 2016
Chapter: Human Resources
To provide policy and procedures for annual seasonal influenza vaccination of employees. The Centers
for Disease Control and Prevention (CDC) recommends annual influenza immunization for all health care
workers to prevent the spread of influenza.
As a healthcare organization, UW Health recognizes and supports the benefits of an annual influenza
program. Influenza vaccination is a key component in the prevention of influenza to patients and co-
workers along with appropriate hand hygiene and standard precautions, including cough etiquette.
II. POLICY ELEMENTS
All covered persons are required to either receive an annual vaccine or provide a waiver as required by
their employer by a deadline established at the beginning of the flu vaccine season. University of
Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical Foundation (UWMF)
employees can receive a vaccine/waiver form through Employee Health Services (EHS). University of
Wisconsin School of Medicine and Public Health (UWSMPH) employees and students can receive the
vaccine/waiver form through University Health Services or through their own provider.
This policy applies to all faculty, staff, and students; both part-time and full-time, including temporary,
per diem and Graduate Medical Education trainees. This policy also applies to all volunteers who work in
UW Health facilities, contract employees, and students on clinical rotation in UW Health facilities. For
purposes of this policy, all persons affected shall be referred to as "employees" even though no
employment relationship may exist. Affiliation agreements and contracts should place the responsibility
for this requirement on the school or agency.
A. All employees are required to receive an influenza vaccine annually or provide a waiver as
required by their employer by a date (the deadline) that is established and communicated by
Employee Health Services at the beginning of the flu vaccine season. Waivers do not need to be
submitted annually. Employees may revoke their waiver in the future with proper documentation.
Falsification of waivers may be cause for discipline up to and including termination.
B. Employees who receive exemptions due to waivers are encouraged to wear surgical masks when
working in a patient care area within 3 feet of patients when there is the presence of influenza in
the community as defined by the Hospital Epidemiologist.
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C. Employees may choose to receive the vaccine from another provider, but must provide
documentation of the vaccine to Employee Health by the deadline of each year.
D. Employee Health will notify employees who are out of compliance and their managers at the end
of the regularly scheduled flu vaccine clinics each year. Managers should monitor employee
compliance and encourage employee participation. Managers will be notified of employees who
received a vaccine waiver so that they can encourage the employee to mask when providing
E. Any employee who is not compliant with this policy by the deadline will be disciplined in
accordance with the policies of the organization they are employed by. (UWHC and UWMF
employees will be placed on an unpaid administrative leave until documentation of vaccination or
completed waiver is received. The employee will be returned to work once the requirement is
completed. Failure to complete this work requirement within 5 days will result in discipline up to
and including termination. Physicians who are non-compliant will receive an administrative
suspension of their privileges until the requirement is completed.
F. Employees who are hired during the influenza season must comply within 7 days of the first day
worked. Records will be maintained documenting vaccinations and waivers.
G. If a national vaccine shortage occurs, UW Health leadership may modify, suspend or revoke all
or part of this policy.
Centers for Disease Control and Prevention; Immunization of Health-Care Personnel Recommendations
of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. 7):1-48
Sr. Management Sponsor: VP, Human Resources Operations
Author: Manager, Employee Health Services; Director, Recruitment, Employee Health and
Reviewer(s): Medical Director, Employee Health Services; Hospital Epidemiologist
Approval committee: Infection Control Committee; UW Health Administrative Policy and
UW Health Chief Administrative Officer
Previous revision: 102013
Next revision: 102019