8/11/2019 Influenza Med Exemption Template 2014

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2014-20

Duke University Employee Occupational Health & Wellness (EOHW)Medical Exemption for Influenza Vaccine Application

Employee to complete the following information:

Name (last, first) __________________________________ Duke Unique ID_____________________

Job Title ____________________________________ Work Area_______________________________

Best Phone Number ______________________ Email Address:____________________________

Submit this completed form to EOHWflu@duke.edu or FAX to 919-681-0555 no later than Monday, October 20, 2014. Yo

will be notified by email from EOHW by Monday, October 27, 2014 as to whether or not your exemption application has b

accepted. Should an active email account not be available, you will be contacted at the phone number you provided abov

Information will be kept only in your confidential EOHW record. After review and acceptance of this information your OES

compliance record will be updated within one week. You may check your OESO safety compliance record to verify your

information at:http://www.safety.duke.edu/

A panel of Employee Occupational Health and Wellness and Infectious Disease physicians will review explanations submitt

as an other reason for medical contraindication, and may not be accepted. If the application for exemption is denied, th

employee may chose to receive the vaccine or provide supplemental information for further review. Additional informatio

available at the following websites :

Literature on egg-free vaccination:http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM336020

Medical Exemption to be completed, signed and dated by healthcare provider (self-completed forms will not

considered) Since egg free flu vaccine is available, history of egg allergy will not be accepted as a routine medical

exemption.As with other injectable flu vaccine types, the egg free option is an FDA approved, safe and effective inactivate

vaccine. Unlike current flu vaccines, the egg free does not use any form of eggs in its production. The egg free vaccine is

approved for persons 18 years of age or older.

The healthcare provider completing this form verifies that different methods of vaccinating against influenza have been

considered, and that the following medical contraindication precludes vaccination for influenza.

My patient has the following medical condition and I verify cannot receive influenza vaccine:

History of Guillain-Barr syndrome with medical documentation.

Anaphylactic reaction due to components of flu vaccine. Describe reaction:_________________________

Other medical contraindication described below:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Signature of Healthcare Provider:_______________________________________ Date:____________________

Printed name:___________________________________ Practice name: _______________________________

Telephone number:______________________________

http://www.safety.duke.edu/http://www.safety.duke.edu/http://www.safety.duke.edu/http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM336020.pdfhttp://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM336020.pdfhttp://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM336020.pdfhttp://www.safety.duke.edu/