In seeking an exemption from the Influenza (Flu) vaccination:
1. I have been informed regarding the purpose, need, risk, and benefits for the required vaccine(s). Texas Children's, the CDC Advisory Committee on Immunization Practices, and the Texas Department of Health have strongly recommended that the vaccine(s) be given to all persons who have been screened and determined to be candidates for the vaccine(s). I understand that my exposure to patients and others at Texas Children's puts me at risk of acquiring the disease. I consent to the release of this request and any supporting documentation to all such representatives of Texas Children's, on a need-to-know basis, in order for the representatives to carry out their duties and to act on my request for an exemption. I understand that I may be requested to provide additional documentation substantiating my exemption request, and that my exemption request may be subject to individual or committee review. I understand that my request for an exemption may not be granted if it is not reasonable or if it creates an undue hardship to Texas Children's. If my request for exemption is based on a temporary medical condition, I acknowledge that I will be fully vaccinated against Influenza (Flu) within 30 days of the resolution of my medical condition.
I acknowledge the above statement
2. I understand that, if I am granted an exemption, I may be subject to reassignment to an alternate and available unit. Also, I may be required to wear additional PPE, undergo regular Influenza (Flu) testing, and/or conform to other alternative infection control measures. Texas Children's does not permit discrimination or retaliation against employees who are granted an exemption.
I acknowledge the above statement
3. Even if Texas Children's grants this exemption, I understand that I may be required to furnish additional information or supporting documentation from me and/or my medical provider(s), as circumstances evolve in the future. Likewise, I understand that this exemption, if granted, is subject to change at the discretion of Texas Children's in the future. I may be asked to recertify my exemption on a regular basis.
I acknowledge the above statement
4. In signing the Immunization Exemption Request Form, I acknowledge that I have read this document in its entirety and fully understand it. I understand and agree that any misrepresentation on my behalf may result in corrective action, up to and including termination.
I acknowledge the above statement
In seeking an exemption from the Influenza (Flu) vaccination:
1. Texas Children's requires all employees and candidates for employment, regardless of their patient care interactions, to be vaccinated against influenza on an annual basis. I understand that there is risk for potential exposure to vaccine-preventable disease(s) for which immunizations have not been administered. I believe the required influenza immunization conflicts with my sincerely held religious beliefs, observances, or practices.
I acknowledge the above statement
