Influenza Vaccine Assessment

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 adult students practicing 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)

Are you a student or a provider?(Required)

Expected time frame of student in Mercer Health Facility (estimated start and end date):(Required)

Clinical Placement Department(s):(Required)

Name of Instructor:(Required)

Name of School:(Required)

Job Title:(Required)

Specialty:(Required)

Expected time frame of provider in Mercer Health Facility (estimated start and end date):(Required)

Please Complete the section below:

Have you received the Influenza Vaccination for the 2024-2025 flu season?(Required)

Please identify a reason you did not receive the Influenza Vaccination for the 2024-2025 flu season:(Required)

History of severe allergic reaction (i.e. anaphylaxis) to egg protein

Severe allergic reaction (i.e. anaphylaxis) to influenza vaccination in the past

History of Guillain-Barre Syndrome within 6 weeks of influenza vaccination

Religious Belief

Please describe your reaction:(Required)

Please upload a copy of your Vaccination Record.(Required)

Max. file size: 300 MB.

Signature(Required)

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