Influenza Management Information System

Vaccination Status Form

As per the Prevention and Management of Influenza Policy (VI-d-120-124),all Sinai Health System employees are required to provide their Influenza Vaccination Status if they receive the influenza vaccination elsewhere or are declining the vaccination (for medical or personal choice reasons). This will ensure that your records with Occupational Health is accurate should an influenza outbreak occur. If you are submitting your vaccination record, please e-mail it to flu@sinaihealth.ca or fax it to Occupational Health at 416-361-2663. If you are declining the vaccine please complete below:

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Last Name	Please Enter Last Name
First Name	Please Enter First Name
Manager Name:	Please Enter Manager Name
Department	Please enter Department name
Position	Please enter Position name
Contact Email	Please enter Email
Contact Phone Number	Please enter Phone number
FLU VACCINATION SECTION
Decline	Please check the most appropriate box from the 2 options below: I have a medical reason for not receiving the 2020 influenza vaccine I have chosen not to receive the 2020 influenza vaccine SHS strongly encourages all staff to be immunized against influenza and require any staff declining vaccination to be aware of the facts before doing so. I have read the Flu Information for 2020
Other/ Notes:
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