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1 ADMINISTRATIVE POLICY AND PROCEDUREE MANUAL Workforce Influenza Immunization Program Effective Date: September 1, 2012 Policy # Reviewed/Revised Date: September 10, 2013 Page: 1of 2 Purpose: The objective of this policy is to protect patients, employees, physicians, students, contractors, volunteers and the community from influenza by conducting mandatory annual immunization of The Chester County Hospitall and Health System entire workforce. Policy: Annual influenza immunization is a requirement for all members of the staff. For the sakee of brevity in this policy, staff will be defined as employees, active medical staff including allied health professionals, volunteers, students and contract personnel. Individuals must meet the requirements of this policy as a condition of employment or service. New employees must comply prior to the date upon which their employment or service with The Chester County Hospital and Health System commences. Existing employees will be expected to comply at the beginning of influenza seasonn each year. Procedure 1. Each individual is required to be immunized by December 1. In our area, the influenza season is generally considered to commence around October 1, and may extend through April or beyond. Therefore, unless vaccine is unavailable, immunization will be required by December 1 of each calendar year. 2. Individuals new to The Chester County Hospital and Health System are required to comply with the immunization standard noted above unless they are hired after April 30 of the calendar year and before the following influenza season s immunizations are available. 3. The Chester County Hospital and Health System will provide immunizations to its staff and volunteers without charge. Individuals may also choose to be immunized through other sources, but will do so at their own expense and with the understanding that they must then provide to The Occupational Health Center written evidencee of immunization. Such written evidence must include documentation and manufacturer name of the vaccine, the lot number, the date given, the site of the injection and the person administering the vaccine. 4. In the event of an influenza vaccine shortage, circumstances will be evaluated by the Senior Vice President for Medical Affairs in consultation with the Infection Preventionn Director and the Director off Human Resources and Organizational Development. If necessary, immunizations may be provided to members of the workforce on a priority basis based upon job function, risk of exposure and other criteria as defined by the Centers for Disease Control. 5. Exemptions to immunization may be granted for medical contraindications or religious beliefs. a. The decision to honor a request for medical exemption will be considered in light of the guidance provided by the Centers for Disease Control and Prevention, including: i. Documentation of severe allergic reaction to eggs ii. Documentation of previous severee allergic reaction to a component of the vaccine iii. History of Guillain-Barre health condition documented by a physician or their designee. syndrome within six weeks of receiving a previous flu vaccine iv. A serious Individuals seeking exemption to the immunization policy based upon medical contraindications must complete the Request for Medical Exemption from Influenza Vaccination form, submitt the form and appropriate documentation and approval for consideration through The Occupational Health Center. Each request will be evaluated individually and a decision rendered by The Occupational Health Center. All requests for medical exemption must be submitted no later than November 1. A written response to the exemption request will be provided within five business days. 1

2 b. c. Individuals seeking exemption to the immunization policy based upon religious beliefs must complete the Request for Religious Exemption from Influenza Immunization form. The request must include documentation on official letterhead from their clergy explaining the request for exemption. Submit the form and attachment to Human Resources and Organization Development. Prior vaccination history will be considered when evaluating requests for religious exemption. Requestss will be evaluated by the Senior Vice President for Medical Affairs, the Director of Infection Prevention and the Director of HROD. All requests must be submitted by November 1 and a written response will be provided within five business days. Exemptions i. If an exemption is granted, the member of the workforce will be formally notified of that fact in writing. ii. If an exemption is granted based upon a temporary medical condition, said exemption will expire at the conclusion of the influenza season. Anyone thenn seeking further exemption must submit a new request for exemption. If exemption is granted permanently, the staff member will not be required to submit additional request for exemption unless vaccine components change, thereby eliminating the basis on whichh the exemption had been granted. 6. Failure to Comply Failure by a member of the workforce to comply with the influenza immunization policy will ultimately result in suspension of the relationship with The Chester County Hospital and Health System and in the case of employed staff, this would be without pay. Staff who are suspended on this basis will be affordedd two weeks to comply with the immunization mandate or suffer a permanent termination of their relationship with The Chester County Hospital and Health System. Disciplinary action for non-compliance. i. Failure to comply by November 1 will result in a written reminder of non-compliance status and the December 1 deadline for compliance. ii. November 15 a written warning will be issued. iii. December 1 a notice suspension. iv. December 15 termination Key Contact: Charleen Faucette Director, Infection Control Approval: Dr. Richard Donze Senior Vice President, Medical Affairs 2

3 Request for RELIGIOUS exemption from mandatory influenza immunization program This request must include appropriate documentationn from your clergy on official letterhead and must be received by Human Resources no later than November 1 st to be eligible for review. Please print Date of request: Employee #: (if appropriate) Name of person requesting exemption: Department/work area: I am requesting a religious exemption from The Chester Countyy Hospital and Health System s mandatory influenza vaccine program. I have attached the appropriate documentation that supports my request for exemption. I understand thatt my request will be reviewed and a response provided in writing within 5 business days of receiving my request. Signature of requesting personnel: 3

4 REQUEST FOR MEDICAL EXEMPTION FROM INFLUENZA VACCINATIO ON PART A NAME: DOB: EMP ID #: ph # CELL/HOME: DEPT: ph# WORK: ROLE: EMPLOYEE STUDENT VOLUNTEER MEDICAL STAFF The Chester County Hospital and Health System is committed to protecting its patients, healthcare workers, medical staff, employees, volunteerss and the community from influenza and therefore requires annual influenza vaccination for its employees as a patient and health care personnel safety initiative. For decades, influenza vaccination has been recommended for health care personnel and has been shown to be effectivee in protecting patients from influenza and its complications. Medical exemptions from influenza vaccination are allowed for recognized contraindications, see CDC@ This form is to be completed to request a medical exemption. (Part A) I request an exemption to the annual influenza immunization. I understand that I must provide medical documentatio on of a CDC recognized contraindicationn from my health care provider. (see Part B) I consent to the release of this request and any supportingg medical documentation from my treating physician to the Occupational Health Center and HROD at The CCH and Health System on a need to know basis in order to act on my request for a medical exemption. Signature Date For OHC use only ******* *************************************** Documentation of Employee/Medical Provider contact Medical Exemption Status: Accepted Permanent Temporary Not Accepted Reason Signature Date 4

5 REQUEST FOR MEDICAL EXEMPTION FROM INFLUENZA VACCINATIO ON PART B Dear Physician: Your patient is requesting a medical exemption from the mandatory influenza vaccination program at The Chester County Hospital and Health Systems. Exemptions from influenza vaccination are allowed for recognized contraindications, see CDC at Please complete the form below to request medical exemption for your patient. If you have any questions, please contact Brenda Sampson, RN or Margaret Stroz, MD, Employee Health at the Occupational Health Center at Please fax the completed PART B documentation to (fax) Employee Name: DOB: Physician Name: My patient should not be vaccinated against influenza for thee following reason(s): Recognized contraindication to influenza vaccination (please mark one): Severee allergic reaction to eggs Defined as developing hives, swelling of f the lips or tongue, difficulty breathing Does not generally include gastro intestinal symptoms The amount of egg protein in influenza vaccines is extremely small. People who tolerate eating foods prepared with eggs, such as baked goods, can generally tolerate the influenza vaccine History of previous severe allergic reaction to the influenza vaccine or component of the vaccine Defined as developing hives, swelling of f the lips or tongue, difficulty breathing Does not include sore arm, local reaction, or subsequent upper respiratory tract infection History of Guillain Barre syndrome within 6 weeks of receiving a previous vaccine People with this history can choose to receive the vaccine I certify that my patient has the above contraindication and request medical exemption from the influenza vaccine. I understand that I may be contacted for additional clarification. Name of Physician: Phone # Signature: Date: 5