2014-2015

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. You
will be notified by email from EOHW by Monday, October 27, 2014 as to whether or not your exemption application has been
accepted. Should an active email account not be available, you will be contacted at the phone number you provided above.
Information will be kept only in your confidential EOHW record. After review and acceptance of this information your OESO
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 submitted
as an other reason for medical contraindication, and may not be accepted. If the application for exemption is denied, the
employee may chose to receive the vaccine or provide supplemental information for further review. Additional information is
available at the following websites :
Literature on egg-free vaccination: http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM336020.pdf

Medical Exemption to be completed, signed and dated by healthcare provider (self-completed forms will not be
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 inactivated
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:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Signature of Healthcare Provider:_______________________________________ Date:____________________

Printed name:___________________________________ Practice name: _______________________________
Telephone number:______________________________