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Cardiology
Center for Healthy Weight & Wellness
Childbirth Center
Disease Management Center
Doctors’ Urgent Care
Ear, Nose & Throat (ENT)
Emergency Care
Home Care & Medical Equipment
Inpatient Services
Laboratory Services
Mental Wellness
OB/GYN & Women’s Health
Occupational Health
Orthopedics
Outpatient Center
Pain Management
Pediatrics
Primary Care
Pulmonology & Respiratory
Radiology & Imaging
Sleep Care
Surgical Services
Therapy & Rehabilitation
Urology
Virtual Care
Providers
Patient & Visitor Info
Map & Parking Information
Know Where to Go
Gift Shop
Billing
Forms
Patient Stories
About
Careers
Job Shadowing
Volunteer Services
Community Outreach
Quality & Excellence
Patient Stories
MED Foundation
Make a Donation
Delivering on a Promise
Charity Ball
Corvette Raffle
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Scholarship Program
Ways to Give
The Healing Garden
Friends of the Foundation
Contact Us
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Annual Influenza Vaccine Documentation / Exemption
The Centers for Disease Control and Prevention recommends the influenza vaccine (flu shot) for everyone over 6 months of age, including healthcare workers. Mercer Health is required to report the number of healthcare workers, providers, volunteers, students and others affiliated that practice within the facility that received the vaccination or filed an exemption from receiving the current influenza vaccine. The reporting period for influenza vaccine is from October 1 to March 31 each year.
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Employee ID
Department
(Required)
Best Phone Number
(Required)
Role at Mercer Health:
(Required)
Mercer Health Employee
Provider
Contract Employee
Volunteer
Student
Other
Other Role:
(Required)
Please Complete the section below:
Have you received the Influenza Vaccination for the 2025-2026 flu season?
(Required)
Choose one
Yes, I have received the Influenza Vaccination for the above flu season.
No, I did not receive the Influenza Vaccination for the above flu season.
Please identify a reason you did not receive the Influenza Vaccination for the 2024-2025 flu season:
(Required)
Medical Exemption: Medical exemption requests may be considered either temporary or permanent depending on the condition.
Religious Exemption: All religious exemption requests are considered temporary and will be reviewed annually.
Religious Exemption:
(Required)
I am requesting an exemption from the 2025-2026 influenza vaccine requirement at Mercer Health due to my sincerely held religious and spiritual beliefs that prohibits vaccination.
I am requesting an exemption from the 2025-2026 influenza vaccine requirement at Mercer Health because of the following medical reason that is documented by my medical provider:
(Required)
History of previous severe allergy to a component of the vaccine or history of severe reaction to the flu vaccine (this does not include a sore arm or localized reaction).
Previous history of Guillain–Barré Syndrome within 6 weeks of a prior influenza vaccine (people with a history of Guillain–Barré Syndrome may choose to receive the vaccine).
I have a disability for which exemption status is the only reasonable accommodation.
Other
Other Medical Reason:
Please upload a copy of your Vaccination Record.
(Required)
Max. file size: 300 MB.
I understand my risks of not being vaccinated and agree to follow the organizations non-vaccinated policies. These may include PPE and isolation procedures. I agree to report any signs or symptoms to my supervisor and/or Employee Health as indicated.
Yes, I understand.
Signature
(Required)
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