Apply for the Influenza Vaccination Honor Roll

Has your organization been listed on the Honor Roll
previously? Check Immunize.org's list of existing honorees for
your institution. Are you already listed?

Additional information you wish to share:

Can staff opt out of receiving influenza vaccination
for MEDICAL reasons?

Please indicate which consequences apply
if the staff person refuses vaccination for
MEDICAL REASONS.

Check all that apply:

Can staff opt out of receiving influenza vaccination
for RELIGIOUS reasons?

Please indicate which consequences apply
if the staff person refuses vaccination for
RELIGIOUS REASONS.

Check all that apply:

Can staff opt out of receiving influenza vaccination
for reasons OTHER THAN MEDICAL OR RELIGIOUS?

Please indicate which consequences apply
if the staff person refuses vaccination for
OTHER REASONS.

Check all that apply:

In your healthcare setting, what are the dates that
wearing a mask begins and ends, and how are
those dates determined?

During a work shift, what are the rules determining when
an unvaccinated staff member must wear a mask?

Check all that apply:

Please tell us who is covered by the mandate :
  All healthcare personnel employed
  in the facility

  All healthcare personnel who come into the
  facility to see patients (e.g., all non-hospital-
  based physicians)

  All healthcare personnel with patient contact

  Clerical staff

  Janitorial staff

  Laboratory staff

  Dietary staff

  Students

  People who volunteer in the facility

Approximately how many people are covered
by this mandate? (Enter integers only.)

What is/was the implementation date?
(Provide precise MM/DD/YY if known.)

Please provide any additional information
about the mandate or any additional
comments you would like to share:

Please provide Internet links to any
information about the mandate, such as
press releases or organization web page: