Can the form be signed electronically?

Yes. Electronic signatures generally satisfy U.S. law under the ESIGN Act (15 U.S.C. §7001) and state UETA statutes when the signer’s intent, consent, attribution, and record retention are documented. Verify state-specific rules for any excluded categories or required disclosures.

Do HIPAA rules apply to this form?

If the declination contains protected health information, HIPAA privacy and record-retention rules apply; covered entities must safeguard PHI, execute a BAA with vendors who process PHI, and retain records per 45 CFR §164.530(j).

Is witness or notarization required?

Not typically for declination forms; witness or notarization requirements vary by state and employer policy. Confirm local rules and facility protocols. When notarization or witness signatures are required, follow state notary rules and retain supporting documentation.

How long must records be kept?

Retention depends on record type: HIPAA requires six years (45 CFR §164.530(j)), IRS rules impose three-year minima for tax-related records (IRC §6501(a)), and employment records have specific I-9 retention periods (8 CFR §274a.2). Check state rules for extensions.

Can employees change or revoke a declination?

Employers should maintain a process to document revocations or subsequent acceptance of vaccination; an employee may change their decision and sign a new form. Treat the most recent signed record as controlling and update personnel and medical files accordingly.

What if the form is incomplete or unsigned?

Incomplete or unsigned forms should be returned for completion; retaining such documents creates compliance risk. Establish a remediation workflow to verify counseling occurred, obtain missing signatures, and document any attempts to secure completion before relying on an incomplete record.

Electronic Signature
Templates
Healthcare
Healthcare Influenza Declination Form

Healthcare Influenza Declination Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare Influenza Declination Form

Purpose: This form documents the patient's voluntary decision to decline the influenza (flu) vaccine for the current influenza season. By signing below the patient confirms that the vaccine was offered, that the risks and benefits were explained, and that the patient understands the potential consequences of refusal.

Patient Information

Patient Full Name

Date of Birth

Gender

Address

Primary Phone

Emergency Contact (Name & Phone)

Insurance Information

Insurance Provider

Policy Number

Group Number

Subscriber Name

Medical History (Relevant to Vaccination)

Current Medications Allergies (including vaccine components) Prior Surgeries / Significant Medical History Chronic Conditions

Influenza Vaccine Declination

I acknowledge that I was offered the influenza vaccine for the current influenza season and that the risks, benefits, and alternatives were explained to me. I understand that by declining vaccination I may be at increased risk for influenza and possible complications, and that I may transmit influenza to others including vulnerable persons.

Reason(s) for Declining (check all that apply)

Personal preference / do not want the vaccine

Religious or philosophical belief

Medical contraindication (explain below)

Other (explain below)

Acknowledgment and Certification

By signing below I affirm that: (1) I have had the opportunity to ask questions and have received answers to my satisfaction; (2) I understand the risks associated with declining influenza vaccination, including the increased risk of acquiring and transmitting influenza; (3) I release the healthcare provider and facility from responsibility for consequences that may result from my decision to decline the vaccine, except for harms resulting from negligence or willful misconduct by the provider; and (4) I understand that I may request the influenza vaccine at any later time during the current influenza season and that acceptance at a later date will be documented in my medical record.

I understand this declination will be filed in my health record and may be used for administrative or public health purposes consistent with law.

Authorization Expiration Date

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered the facility's Notice of Privacy Practices and understand that information about this declination will be entered into my medical record and handled in accordance with applicable privacy laws.

I acknowledge receipt (or offer of receipt) of the Notice of Privacy Practices.

Offer Documentation (to be completed by staff)

Name of Staff Offering Vaccine

Staff Title/Role

Date Offered

Patient Printed Name:

Signature:

Relationship to Patient (if signing for patient)

Date:

What the Healthcare Influenza Declination Form Is

The Healthcare Influenza Declination Form documents an individual’s informed decision to decline an offered influenza vaccination in a healthcare setting. Organizations use it to record the declination, capture signed acknowledgment of counseling or education provided, and maintain a clear audit trail for occupational health programs. When completed it becomes part of an employee or patient medical record and may trigger alternative infection-control measures. Electronic completion and signature are generally enforceable under federal ESIGN law and state UETA statutes when intent, consent, attribution, and retention requirements are met.

Why documenting a declination matters

Recording a declination creates a documented acknowledgment that supports occupational health compliance, reduces liability by demonstrating informed refusal, and preserves consistent infection-control records. Properly executed forms help employers track exemptions, manage staffing decisions, and provide evidence in regulatory or legal reviews.

Who typically completes and handles this form

Clinicians, occupational health teams, human resources, and employees or contractors commonly complete or collect the Healthcare Influenza Declination Form for workplace and patient-safety records.

Healthcare workers and staff who decline vaccination but remain patient-facing.
Employees with medical, religious, or personal objections documented per employer policy.
Contractors, volunteers, and students entering clinical areas required to provide declination.

Facilities should retain the signed declination alongside vaccination records and follow applicable privacy rules when storing or sharing the form.

Essential sections to include on the form

Well-designed Healthcare Influenza Declination Forms combine clear statements, informed refusal acknowledgement, signer identity, date, counseling notes, and recordkeeping fields to support compliance and traceability.

Declination Statement

A concise declaration that the signer refuses the influenza vaccine after being offered; include language confirming counseling was offered and that the signer understands risks and alternatives.

Signer Identity

Enter the signer’s full legal name exactly as on file, job title or relationship to the facility, department, and an employee or ID number to reliably match the declination to personnel records.

Date and Location

Record the exact date using MM/DD/YYYY and the facility name or unit location where the declination occurred; location details aid contact tracing and compliance reporting.

Counseling Notes

Summarize counseling provided about vaccine benefits, risks, and alternatives, note the staff member who counseled the signer, and record whether printed or electronic educational materials were supplied.

Witness or Clinician

Name and professional role of any witness or clinician who observed the declination or provided counseling; include contact information for follow-up if required by policies.

Electronic Audit Trail

For e-submissions, include an audit trail recording timestamps, signer IP, authentication method, and certificate of completion to demonstrate intent, attribution, and retention under ESIGN requirements.

Step-by-step: completing the declination form

Follow this sequence to complete the Healthcare Influenza Declination Form accurately and ensure the record meets legal and employer documentation requirements.

01

Confirm Offer: Verify vaccine was offered and counseling provided.
02

Fill Personal Info: Enter full name, title, department, and ID.
03

Record Declination: Check declination box and state reason briefly.
04

Sign and Date: Signer signs, dates, and witness if required.

Submission and routing overview

This overview shows common routing steps when the declination form is submitted electronically or on paper and how records are stored.

Upload: Attach PDF or complete online form.
Assign Recipient: Route to occupational health or HR.
Authenticate Signer: Use email, SMS, or stronger ID verification.
Archive: Store in secure medical record system.

How to configure the online workflow

Configure e-submission workflow to match institutional approval paths, authentication levels, and retention settings before wide deployment.

Field	Configuration
Authentication Level	Email or SMS code; use MFA if required
Required Fields	Make name, date, and counseling notes mandatory.
Conditional Fields	Show counseling notes only if declination selected.
Storage Location	Save to EHR or secure HR folder
Notifications	Email HR and occupational health on submission

Technical requirements for e-submission and storage

Electronic submission supports PDF, DOCX, or web form formats and commonly integrates with EHR or HR systems for recordkeeping.

File Formats: PDF, DOCX, HTML accepted
Integrations: EHR, HRIS, and cloud storage
Authentication: Email, SMS, or multi-factor methods

Required fields at a glance

Full Name: Exact legal name as on ID

Date of Declination: Use MM/DD/YYYY format for date

Facility/Unit: Facility name and department

Job Title/Status: Employee, contractor, volunteer, student

Counseling Notes: Brief summary of topics discussed

Signature & Date: Signer signature and MM/DD/YYYY

Common mistakes to avoid

Failing to document that counseling was offered or provided can undermine the validity of the declination and complicate occupational health follow-up during exposures.
Using inconsistent signer names or omitting employee identifiers makes it difficult to match the declination to HR records and may trigger re-verification requests.
Allowing unsigned or backdated forms into the record can create compliance gaps and weaken defenses in employment or regulatory disputes.
Storing declination forms in unsecured locations or sharing them without proper HIPAA safeguards risks PHI disclosure and potential HIPAA violations.

Possible penalties and operational risks

HIPAA Breach: Potential civil penalties and corrective action

OSHA Concerns: Possible OSHA citations

I-9 Impact: Affects employment verification

Liability Exposure: Increased employer legal risk

Recordkeeping Fines: Fines for incomplete records

Operational Disruption: Staffing and scheduling impacts

Timelines, deadlines, and expected processing

Key dates and timelines indicate when to collect declinations, report aggregate data, and retain records according to employer policies and regulatory requirements.

When to Collect:

At time vaccine is offered or during enrollment period.

Reporting Periods:

Quarterly or annually per facility policy or state rule.

Record Retention:

Retain per retention schedule; HIPAA six-year baseline.

Employee File Update:

Update personnel file immediately after signature.

Audit Access:

Make records available for internal or regulatory audits.

Real-world examples of declination use

Real-world examples show how declination forms fit into vaccination programs and occupational health casework across healthcare settings.

Hospital Occupational Health

A large hospital documents employee declinations during annual flu campaigns to track coverage and exemptions across departments.

Triggers mask or work restrictions.
The occupational health team stores the signed declination in the employee medical file, records counseling notes, and uses aggregated data to inform targeted outreach and report compliance metrics to risk management and hospital leadership.

Long-term Care Facility

A skilled nursing facility records resident or staff declinations to document informed refusal and to adjust resident protection measures.

Prompts enhanced PPE use for affected staff.
Management attaches declinations to resident files, communicates aggregate counts to public health during outbreaks, and retains records per HIPAA and state retention rules for potential audits.

Pricing and feature comparison for eSignature vendors

Compare common eSignature vendors on price and critical features relevant to Healthcare Influenza Declination Form workflows and HIPAA compliance.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Practical best practices for form accuracy and defensibility

Practical tips reduce errors and improve acceptability of declination forms across clinical and administrative operations.

Use plain language and consistent wording

Phrase the declination in clear, non-judgmental language that states the offer was made, the individual declined, and counseling was offered; standardized wording reduces disputes and supports consistent recordkeeping across departments and facilities.

Require minimal mandatory fields for clarity

Limit mandatory fields to those necessary for identification, counseling, and auditability; avoid optional free-text that is never reviewed, and structure reasons using controlled choices to simplify reporting and analysis.

Ensure secure storage and access controls

Store signed declination forms in secure, access-controlled systems with audit logs; restrict PHI access to authorized occupational health and HR personnel and ensure retention schedules comply with HIPAA and state requirements.

Train staff on form handling and privacy

Provide training on offering the vaccine, documenting declinations, completing counseling notes, and privacy obligations; periodic audits, competency checks, and version control of the form reduce errors and support defensible practices.

Frequently asked questions about the declination form

Frequently asked questions about completing, signing, and storing the Healthcare Influenza Declination Form are answered below to reduce uncertainty and prevent common errors.

Need help? Contact support

Can the form be signed electronically?
Yes. Electronic signatures generally satisfy U.S. law under the ESIGN Act (15 U.S.C. §7001) and state UETA statutes when the signer’s intent, consent, attribution, and record retention are documented. Verify state-specific rules for any excluded categories or required disclosures.
Do HIPAA rules apply to this form?
If the declination contains protected health information, HIPAA privacy and record-retention rules apply; covered entities must safeguard PHI, execute a BAA with vendors who process PHI, and retain records per 45 CFR §164.530(j).
Is witness or notarization required?
Not typically for declination forms; witness or notarization requirements vary by state and employer policy. Confirm local rules and facility protocols. When notarization or witness signatures are required, follow state notary rules and retain supporting documentation.
How long must records be kept?
Retention depends on record type: HIPAA requires six years (45 CFR §164.530(j)), IRS rules impose three-year minima for tax-related records (IRC §6501(a)), and employment records have specific I-9 retention periods (8 CFR §274a.2). Check state rules for extensions.
Can employees change or revoke a declination?
Employers should maintain a process to document revocations or subsequent acceptance of vaccination; an employee may change their decision and sign a new form. Treat the most recent signed record as controlling and update personnel and medical files accordingly.
What if the form is incomplete or unsigned?
Incomplete or unsigned forms should be returned for completion; retaining such documents creates compliance risk. Establish a remediation workflow to verify counseling occurred, obtain missing signatures, and document any attempts to secure completion before relying on an incomplete record.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now