Flu vaccination program consent form

Indicates required field

When should I use this form?

This form must be completed before seeking reimbursement for the cost of the flu vaccine. Please note that it does not need to be signed for vaccinations administered at Parliament House.

To receive reimbursement for the cost of the vaccine attach the receipt for the cost of the vaccine below.

One file only.
5 MB limit.
Allowed types: gif, jpg, png, pdf, doc, docx.

I understand that the cost of the flu vaccine may be reimbursed as part of a workplace vaccination program for employees who have voluntarily requested to be vaccinated.

I acknowledge and understand that I do not have to be vaccinated if I do not want to.

I confirm that I am aware of any potential risks resulting from the vaccine, including:

mild local reactions at the injection site, including a lump (induration),soreness, redness and swelling;
more common reactions that may include fever (> 37.5°C), headache, chills,malaise and myalgia; and
very rarely, severe allergic reaction.

I acknowledge and accept that the Department of Finance has no responsibility in the event that I suffer any side effect resulting from the workplace vaccination program for employees.

Name

Employers office

Your email address

An email will be sent to this address with the details above for your records.