Patient was offered an annual Influenza vaccine today but declined immunization.


* indicates required

Influenza Vaccine Refused

Influenza Vaccination Refusal

NOTE: Do NOT use this form if the patient has already received the vaccine elsewhere (outside of VA). Return to the previous screen and select Reason = "Received vaccine elsewhere".

The following information will be added to the Comments / Notes:

<% questionsCollection.each( function(item){ %>

<%= item.get('legend') %> <%= item.get('user_response') %>

<% }); %>
<% if (typeof vaccinator !== 'undefined' && !_.isEmpty( vaccinator )) { %>
value="<%= vaccinator.title %>" <% if ($.trim(vaccinator.title) !== "") { %> readonly="readonly" disabled="disabled" <% } %> <% } else { %> value="" <% } %> />
<% } %>