Johns Hopkins Safety Manual Policy Number HSE 048

Transcription

1 Mandatory Influenza Vaccination Page 1 of 18 The Johns Hopkins Institutions recognize its responsibility to provide employees a workplace free of recognizedhazards. Influenza( theflu )isacontagiousrespiratoryillnesscausedbyinfluenzaviruses.itcancausemildto severe illness and, at times, can lead to death. The most effective way to prevent infection from an influenzavirusisthroughannualinfluenzavaccination. Annual influenza vaccination protects patients and staff and the integrity of the Johns Hopkins workforce.thispolicyisintendedtomaximizevaccinationratesagainstinfluenzaamongthepersonnel of the Johns Hopkins Institutions, especially those whose work requires their presence in clinical settings.thegoalistoprotectpatients,employees,employees familymembers,othersaffiliatedwith JohnsHopkins,andthebroadercommunityfrominfluenzainfectionthroughannualimmunization. DEFINITIONS A. HealthCarePersonnel(HCP):Allemployees,faculty,residents,fellows,temporaryworkers,trainees, volunteers, students, vendors, and medical staff, regardless of employer, who provide ongoing servicesorworkinpatientcareorclinicalcareareas.forthepurposesofthispolicy,hcpincludes otherstraditionallyconsidered non"clinical butwhofulfilltheabovecriteria.seeappendix1for examplesofhcp.allsuchpersonsarecoveredbythispolicy. B. Patientcareorclinicalcarearea:Theseincludethephysicalorrecognizedbordersofinpatientand outpatient areas where patients may be seen, evaluated, treated, or wait to be seen. Appendix 2 providesexamplesofsuchareas. C. Patient:anindividualundergoingmedicalassessmentoractivetreatment. POLICY The Johns Hopkins Institutions Joint Committee for Health Safety and Environment approves the followingpolicy: A. As a condition of employment or appointment to the medical staff or access to patient care or clinicalcareareascoveredbythispolicy,asappropriatetoeachcoveredperson scircumstancesand in accordance with patient safety standards, The Johns Hopkins Institutions require HCP (see Definitions) to have annual influenza vaccination or possess an approved medical or religious exception(seeappendices3"6). B. InfluenzavaccinationshallbeprovidedfreeofchargethroughOccupationalHealthServices(OHS)to anyonewithajohnshopkinsorotherrelevantentitybadge. C. Prior to the annual onset of influenza season and when the most current vaccination recommendationsarepublishedbythecentersofdiseasecontrolandprevention(cdc),thejohns Hopkins Institutions Health, Safety, and Environment Department (Occupational Health Services) willinformpersonnelaboutthefollowing: 1. Requirement(s)forvaccination 2. Dateswheninfluenzavaccine(s)areavailable 3. Procedureforreceivingvaccination

2 Mandatory Influenza Vaccination Page 2 of ProcedureforsubmittingwrittendocumentationofvaccineobtainedoutsideJohnsHopkins 5. Procedurefordecliningduetoaqualifiedexception 6. Consequencesofrefusingvaccination D. Annually,HCPmustdooneofthefollowing: 1. Receivetheinfluenzavaccine(s)byDecember1,whichwillbeprovidedfreeofchargethrough OccupationalHealthServices(OHS). 2. ProvideOHSwithproofofimmunizationifanHCPisvaccinatedthroughservicesotherthanOHS (e.g.,privatephysicianoffice,publicclinics)bydecember1.proofofimmunizationmustinclude acopyofdocumentationindicatingthevaccinewasreceived. 3. ComplywiththedesignatedprocedureforobtainingapermissibleexceptionbyDecember1,as describedinthispolicy. EXCEPTIONS A. Medical 1. Exceptionstorequiredimmunizationmaybegrantedforcertainmedicalcontraindications. Standardcriteriawillbeestablishedandinclude: a. Severeallergytothevaccineorcomponentsasdefinedbythemostcurrent recommendationsofthecdc sadvisorycommitteeonimmunizationpractices(acip) ( 18a1_e&source=govdelivery,Appendix4). b. Guillain"Barréwithinsixweeksofapriorinfluenzavaccine. 2. Personnelrequestingexceptionmustsubmitadeclinationform(Appendix3)andprovide documentationofmedicalcontraindications(appendices5aand5b)tooccupationalhealth Services(OHS)byNovember1. 3. ArequestformedicalexceptionwillbeevaluatedindividuallybyOHSwithintwenty(20) businessdaysaftertherequestispresentedtoohs.iftheexceptionisforallergytoeggs,the mostcurrentcdcaciprecommendationswillbefollowedbyohs. 4. Ifexceptionsaregrantedforatemporarycondition,theHCPmustresubmitarequestfor exceptioneachyear.ifexceptionisgrantedforapermanentcondition(e.g.,significantvaccine allergyorhistoryofguillain"barréafterapreviousinfluenzavaccine),theexceptiondoesnot needtoberequestedeachyearunlessvaccinetechnologychangestoeliminatetheissue regardingallergies. B. Religious Ifcandidatesdeclineimmunizationbecauseitconflictswithsincerelyheldreligiousbeliefs,theymust completeandsubmittotheirmanageradeclinationformandarequestforreligiousaccommodation form(appendices3,6a,and6b).uponreceiptofanemployee srequest,theemployee smanagerwill forwardtherequestforreligiousaccommodationformtothedepartmentofhumanresourcesandthe declinationformtoohs.theserequestsmustbereceivedbynovember1andwillbereviewedbythe DepartmentofHumanResourcesasarequestforreligiousaccommodation.Requestsforreligious accommodationsforjohnshopkinsuniversityemployeeswillalsobereviewedbytheofficeof InstitutionalEquity.

3 Mandatory Influenza Vaccination Page 3 of 18 C. RequirementsUponReceivingException Iftheexceptionisgranted,theindividualwillsigneitherelectronicallyorbywrittendocumentation attestingthathe/shewillwearamaskatalltimeswhileinanyjohnshopkinsinstitutions patientcare orclinicalcareareas(seedefinitions)whenwithinsix(6)feetofapatient(seedefinitions)duringthe influenzaseason(asidentifiedbyjhhsepidemiologyandinfectionpreventioninconsultationwiththe JHHSMedicalMicrobiologyLaboratories). COMPLIANCE A. Beginningwiththe2011"2012influenzaseason,anyHCPwhoisnotvaccinatedmustwearasurgical maskwithinsix(6)feetofanypatientandwhenenteringapatientroomduringtheinfluenza season.theeffectivedatesforinfluenzaseasonwillbeidentifiedbythejohnshopkinshealth System(JHHS)EpidemiologyandInfectionPreventionOffice. B. Beginningwiththe2012"2013influenzaseason,influenzavaccinationbecomesaconditionof employmentorappointmenttothemedicalstafforaccesstopatientcareorclinicalcareareas coveredbythispolicy,asappropriatetoeachcoveredperson scircumstances.anyhcpcoveredby thispolicywhofailstocomplywiththevaccinationrequirementwillbesubjecttotherelevant disciplinaryproceduresestablishedbytheirrespectiveinstitutionthatrelatestoconditionof employmentorappointmentoraccess. C. Alsobeginningwiththe2012"2013influenzaseason,allcoveredindividualswhofailtocomplywith therequirementofthispolicywillnotbepermittedtoenterpatientcareorclinicalcareareas(see Definitions)duringtheinfluenzaseason(asdefinedabove). RESPONSIBILITIES HealthCarePersonnel(seeDefinitions) Responsibilitytoreceiveinfluenzavaccinationby thestateddeadlineortocompletethedesignated processforapermissibleexception

4 Mandatory Influenza Vaccination Page 4 of 18 JHHSEIP Establishannualvaccinationrequirements.Define theinfluenzaseason HumanResources Accept,evaluate,andapproverequestsforreligious accommodationsthroughtheirappropriate institutionaloffice.initiatedisciplinaryprocedures forhcpswhodonotcomplywiththispolicy. Answerquestionsrelatedtothispolicy. OccupationalHealthServices Administerandtrackvaccinations.Accept,evaluate, andapproverequestsformedicalexception.ohs willnotifiyhumanresourcesabouttheindividuals grantedmedicalexceptions.ohswillevaluate organizationalhcpvaccinationrates,andfrequency andreasonsforvaccinedeclinationsmonthly betweenseptemberandjanuary.thisinformation willbereportedtothejointcommitteeforhealth SafetyandEnvironmentandHEIC.TheJoint CommitteeforHealthSafetyandEnvironmentand JHHSHEICwillbeprovidedlistsofHCPsnot compliantbydecember1ofeachyear. SupervisorsandManagers EnsurethatallHealthCarePersonnelarevaccinated againstinfluenzaeachyearunlessexceptionhas beengrantedasdescribedinthispolicy.enforce mask"wearingprovisionofthispolicyasapatient safetystandard. VACCINESHORTAGECONTINGENCY Intheeventofaninfluenzavaccineshortage,JHHSHEICandtheOfficeofCriticalEventPreparedness andresponse(cepar)willdetermineanappropriatedistributionplanfortheresourcesavailable.ohs, HEIC,HumanResources,Pharmacy,andAdministrationwillconducttheevaluationwithother departmentsacrossallentitiesincludedasneededwhenvaccineshortagesoccur.influenzavaccinewill beofferedtopersonnelbasedonrisktopatientpopulationcaredfor,jobfunction,andriskofexposure toinfluenza.prioritywillbegiventothosewhoprovidehands"onpatientcarewithprolongedface"to" facecontactwithpatientsand/orhavehighestriskofexposuretopatientswithinfluenza.thosewho areprioritizedtoreceivevaccinewillbeheldtothemandatorystandard.thosewhoarenotprioritized toreceivevaccinewillnotbeheldtothemandatorystandardforthedurationofthevaccineshortage period,andrecommendationswillbeprovidedtothosewhodonotreceivevaccinebyjhhsheicin conjunctionwiththeinstitutionalinfectioncontrolentities. DISSEMINATION Thispolicywillbedisseminatedby: 1. Emergencymanagementsessionsandtrainingsessions 2. In"servicesandgrandrounds 3. JohnsHopkinsInstitutionsintranetsiteandpublications

5 Mandatory Influenza Vaccination Page 5 of CommitteesofJHUandJHHS 5. Newemployeeorientation(Appendix7) 6. HSEwebsite 7. HSEbroadcastcommunicationthrough 8. StatementofAttestation JHU(Appendix8) REFERENCES source=govdelivery Talbot TR, Bradley SE, Cosgrove SE, Ruef C, Siegel JD, Weber DJ. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. InfectControlHospEpidemiol2005;26(11):882"890. Talbot TR. Improving rates of influenza vaccination among healthcare workers: educate; motivate;mandate?infectcontrolhospepidemiol2008;29(2):107"110. Centers for Disease Control and Prevention(CDC); Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR Recomm Rep. 2011; BabcockHM,GemeinhartN,JonesM,DunaganWC,WoeltjeKF.Mandatoryinfluenza vaccinationofhealthcareworkers:translatingpolicytopractice.clininfectdis.2010;50(4):459" 464. RakitaRM,HagarBA,CromeP,LammertJK.Mandatoryinfluenzavaccinationofhealthcare workers:a5"yearstudy.infectcontrolhospepidemiol.2010;31(9):881"888. REVIEW CYCLE Annual APPROVAL Chair,JointCommitteeforHealthSafetyandEnvironment Date

6 Mandatory Influenza Vaccination Page 6 of 18 APPENDICES APPENDIX1:EXAMPLESOFHEALTHCAREPERSONNELASDEFINEDINANDCOVEREDBYTHISPOLICY Examplesofhealthcarepersonnelwhomayprovideservicesinpatientcareorclinicalcareareas(see Definitions,sectionB)includebutarenotlimitedto: 1. Physicians 2. Nurses 3. Pharmacists 4. AlliedHealthProfessionals 5. HospitalityServicespersonnel 6. FacilitiesManagementpersonnel 7. FoodandNutritionServicespersonnel 8. SterileProcessingandMaterialServicestechnicians 9. Patienttransporters 10. EnvironmentalServicespersonnel 11. Clericalpersonnel 12. Students 13. Vendors 14. Volunteers Asindicatedabove,personneltraditionallyconsideredas non"clinical arealsoincludedinthispolicy s definitionofhealthcareprofessionals(hcps). APPENDIX2:EXAMPLESOFPATIENTCAREORCLINICALCAREAREAS PerDefinitions,sectionBincludedinthispolicy,examplesofpatientcareorclinicalcareareasinclude butarenotlimitedto: 1. TheJohnsHopkinsHospital 2. TheJohnsHopkinsOutpatientCenter 3. GreenSpringStationMedicalFacility 4. WhiteMarshMedicalFacility 5. OdentonMedicalFacility

7 Mandatory Influenza Vaccination Page 7 of 18 APPENDIX3:VACCINEDECLINATIONFORMTEMPLATE INFLUENZA VACCINE DECLINATION STATEMENT PLEASE PRINT THE FOLLOWING INFORMATION: Name: Date of Birth: / / address: Phone/Pager No.: Department: Unit/Service Where You work Identification No.: Do you have any direct patient contact? YES NO [Note: Direct patient contact is anyone working within 6 feet of a patient.] PLEASE CHECK THE CORRECT AFFILIATION: JHH JHU/SOM SOM student JHU/SON SON student JHCP JHU/BSPH BSPH student JHU/ASE ASE student Volunteer Other If other, explain: DECLINATION of Annual Influenza Vaccination: I understand that due to my occupational exposure, I may be at risk of acquiring influenza infection. In addition, I may spread influenza to my patients, other healthcare workers, and my family, even if I have no symptoms. This can result in serious infection, particularly in persons at high risk for influenza complications. I have received education about the effectiveness of influenza vaccination as well as the adverse events. I have also been given the opportunity to be vaccinated with influenza vaccine, at no charge to myself. However, I decline influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring influenza, potentially resulting in transmission to my patients. If in the future I want to be vaccinated with influenza vaccine, I can receive the vaccine at no charge to me. I attest that I will wear a mask anytime I am within six feet of a patient for the duration of the influenza season if I do not receive the influenza vaccination. Reason for declining: (Please check all that apply.) I received the vaccine from another facility (Documentation must be provided to Occupational Health). I request a medical exception (The Medical Exception Form must be completed and returned to Occupational Health). I request a religious accommodation (The Religious Accommodation Form must be completed and returned to Occupational Health). Employee Signature: Date: PLEASE FAX OR MAIL THIS TO OCCUPATIONAL HEALTH SERVICES.Homewood Campus East Baltimore Campus The Johns Hopkins University Johns Hopkins Medicine Occupational Health Services Occupational Health Services 3400 North Charles Street The Church Home Professional Office Building W-601 Wyman Park Building 98 North Broadway, Room 421 Baltimore, MD Baltimore, MD Office Office Fax Fax DESIGNATED OFFICE USE ONLY: Declination Statement Received on: / / Approving Staff Signature:

8 Mandatory Influenza Vaccination Page 8 of 18 APPENDIX4:CRITERIAFORMEDICALEXCEPTION Medicalexceptionsinclude: 1. Severeallergytoeggsorvaccinecomponents; 2. Guillain"Barréwithinsixweeksofreceivinganinfluenzavaccine. OHSwillevaluatetheallergyhistoryanddetermineacourseofactionbasedontheseverity. Thosepatientswhoareabletoeateggs,cakeorfoodswitheggproteinwithoutreactionmay receivethevaccine. Individualswhohaveexperiencedlessseverereactionstoegg(e.g.,hivesonly)mayreceive influenzavaccinewiththefollowingadditionalmeasures: 1. Killedinfluenzavaccineformulation(TIV)shouldbeused;preferablyvaccineswithlessthan 0.12mcgofeggproteinshouldbeadministered. 2. Patientsshouldbeobservedfor20"30minutesforsignsofareactionfollowing administrationofeachvaccinedose. IfOHSdeterminesthatthereisahistoryofasevereallergicreactiontothevaccineoritscomponents, anallergyconsultationcanbeoffered.(othermeasures,suchasdividingandadministeringthevaccine byatwo"stepapproachandskintestingwithvaccinearenotnecessary.)thisshouldincludepersons whoreporthavinghadseriousreactionstoegginvolvingsuchsymptomsasangioedema,respiratory distress,lightheadedness,orrecurrentemesis;or,whorequiredepinephrineorotheremergency medicalintervention,particularlythosethatoccurredimmediatelyorwithinashorttimefollowingegg exposure(minutestohours).suchindividualsaremorelikelytohaveaserioussystemicoranaphylactic reactionuponre"exposuretoeggproteins.priortoreceiptofvaccine,suchindividualswillbereferred toanallergyspecialistforfurtherriskassessment.preferablyvaccineswithlessthan0.12mcgofegg proteinshouldbeadministered. IfthepatientreportsahistoryofGuillain"Barréfromanycauseinthepastsixweeks,theindividualmay bereferredtoaneurologistwithexpertiseinthisarea.

9 Mandatory Influenza Vaccination Page 9 of 18 APPENDIX5A:JHHVACCINEMEDICALEXCEPTIONFORMTEMPLATE Dear Physician: Please print information below: Employee Name: Date of Birth: / / Employee Employee Phone #: Department: Manager: Physician Name: Physician Phone #: Request for Medical Exception from Influenza Vaccination JohnsHopkinsHospitalrequiresinfluenzavaccinationsimilartootherrequiredvaccinationssuchas MMRandvaricella.Fordecadesinfluenzavaccinationshavebeenrecommendedforhealthcareworkers becausetheyhavebeenshowntobeeffectiveinreducingtheincidenceofinfluenzaininpatient populations.influenzavaccinationhasalsobeenrecommendedinpregnancybythecentersfor DiseaseControltoprotectpregnantwomen(whoareatincreasedriskofseveredisease)andtoprotect thebabyafteritisborn.theabovenamedemployeeisrequestinganexceptionfromthisvaccination requirement.amedicalexceptionfrominfluenzavaccinationisallowedforcertainrecognized contraindications(cdcmmwrearlyrelease2011;vol.60.availableonline: OccupationalHealthServices,98N.Broadway,Baltimore,MD21231.Shouldyouhaveanyquestions, pleasecontactoccupationalhealthservicesat(410)955"6211orfax:(410)955"1617.thankyou. Theaboveemployeeshouldnotbeimmunizedforinfluenzaforthefollowingreason: History of previous severe allergic reaction and documented allergy testing to indicate an immediatehypersensitivityreactiontotheinfluenzavaccineoracomponentofthevaccine. History of Guillain"Barre Syndrome within six weeks of receiving a previous vaccine. Please provideadetailednarrativethatdescribestheevent. Other Pleaseprovidethisinformationinaseparatenarrative thatdescribestheexceptionin detail(theserequestswillbereviewedonacase"by"casebasis). Clarificationfromtherequestingemployeeandphysicianmayberequested. Icertifythat hastheabovecontraindicationand requestamedicalexceptionfrominfluenzavaccination. PhysicianSignature MedicalLicense#: Date: (Note:SignatureStampNotAcceptable) DESIGNATED OFFICE USE ONLY: Medical Exception Approved on: / / Approving Staff Signature:

10 Mandatory Influenza Vaccination Page 10 of 18 APPENDIX5B:JHUVACCINEMEDICALEXCEPTIONFORM REQUEST FOR MEDICAL EXCEPTION FROM INFLUENZA VACCINATION PLEASE PRINT THE FOLLOWING INFORMATION: Name: address: Department/School: Physician Name: Date of Birth: / / Phone/Pager No.: Supervisor/Manager Physician Phone No.: Dear Physician: Johns Hopkins University requires influenza vaccination similar to other required vaccinations such as MMR and varicella. For decades influenza vaccination has been recommended for healthcare workers because they have been shown to be effective in reducing the incidence of influenza in inpatient populations. Influenza vaccination has also been recommended in pregnancy by the Centers for Disease Control to protect pregnant women (who are at increased risk of severe disease) and to protect the baby after it is born. The above named person is requesting an exception from this vaccination requirement. A medical exception from influenza vaccination is allowed for certain recognized contraindications (CDC MMWR Early Release 2011; Vol. 60. Available online: Please complete the form below. Should you have any questions, please contact Johns Hopkins Medicine Occupational Health Services at Thank you. The above person should not be immunized for influenza for the following reasons (Please check all that apply.): History of previous allergic reaction and documented allergy testing to indicate an immediate hypersensitivity reaction to the influenza vaccine or a component of the vaccine. History of Guilain-Barre Syndrome within six weeks of receiving a previous vaccine. Please provide and attach a detailed narrative that describes the event. Other Please provide this information in a separate narrative that describes the exception in detail (these requests will be reviewed on a case-by-case basis). I certify that has the above contraindication and request a medical exception from influenza vaccination. Physician Signature: Date: Physician Medical License No.: PLEASE FAX OR MAIL THIS TO OCCUPATIONAL HEALTH SERVICES AT THE JOHNS HOPKINS UNIVERSITY.Homewood Campus East Baltimore Campus The Johns Hopkins University Johns Hopkins Medicine Occupational Health Services Occupational Health Services 3400 North Charles Street The Church Home Professional Office Building W-601 Wyman Park Building 98 North Broadway, Room 421 Baltimore, MD Baltimore, MD Office Office Fax Fax DESIGNATED OFFICE USE ONLY: Medical Exception Approved on: / / Approving Staff Signature:

11 Mandatory Influenza Vaccination Page 11 of 18 APPENDIX6A:JHH/JHHSSAMPLERELIGIOUSACCOMMODATIONFORM RequestforReligiousWorkplaceAccommodation TheJohnsHopkinsInstitutionsarecommittedtodiversityandinclusivenessofallouremployees.Areasonable religiousworkplaceaccommodationisachangeintheworkenvironmentorinthewaytasksorresponsibilitiesare customarilydonethatenablesanemployeetoparticipateinhis/herreligiouspracticeorbeliefwithoutundue hardshipontheconductofjohnshopkinsinstitution sbusinessoroperation.toconsideryourrequestfora religiousworkplaceaccommodation,pleaseprovidethefollowinginformation: Part1 ToBeCompletedbyEmployee(additionalsheetsmaybeused,ifnecessary) Name: DateofRequest: Department: ImmediateSupervisor: ReasonforRequest(i.e.,timetopray,leaveforreligiousobservance,religiousattire,etc.): Suggestedreasonableaccommodationtomeetyourrequirementsorlimitations: Isthisatemporaryorpermanentaccommodation(i.e.,annualreligiousevent,dailyreligiousrequirement)? LengthofTime: Days: Shifts:

12 Mandatory Influenza Vaccination Page 12 of 18 Ifyouhaverequestedthisreligiousaccommodationbefore,pleasestateapproximatelywhenthepriorrequest wasmade,thenameoftheindividualwhorespondedandtheoutcomeoftherequest: ReligionTenet(s)Documentation Insomecases,JHHSC/JHHwillneedtoobtaindocumentationorotherauthorityregardingyourreligiouspracticeor belief.wemayneedtodiscussthenatureofyourreligiousbelief(s),practice(s)andaccommodationwithyour religion sspiritualleader(ifapplicable)orreligiousscholarstoaddressyourrequestforanaccommodation. Ifrequested,canyouobtaindocumentationorotherauthoritytosupporttheneedforanaccommodationbased onyourreligiouspracticeorbelief? Yes No VerificationandAccuracy IverifythattheaboveinformationiscompleteandaccuratetothebestofmyknowledgeandIunderstandthat anyintentionalmisrepresentationcontainedinthisrequestmayresultindisciplinaryaction. Ialsounderstandthatmyrequestforanaccommodationmaynotbegrantedifitisnotreasonableorifit createsanunduehardshiponmyemployer. Signature: Date: PrintName: SummaryofNextSteps 1. Thisrequestwillbereviewedwithyouandacknowledgedbyyoursupervisor. 2. YoursupervisorwillthensubmityourrequesttotheappropriateHumanResourcesrepresentativefor consideration. 3. Youwillbenotifiedofthedecisionand/ortheproposedaccommodation. 4. Ifyoudisagreewiththedecisionorproposedaccommodation,pleasecontacttheDepartmentof HumanResources,forassistance.

13 Mandatory Influenza Vaccination Page 13 of 18 Part2 Tobecompletedbyimmediatesupervisor(andadditionalmanagers,ifapplicable) InteractiveDiscussionDate: Employee ssuggestedaccommodation: ResultsofInteractiveDiscussion: EvaluationofImpact(ifany): Accepted:NotAccepted:IfNotAccepted,Why?:

14 Mandatory Influenza Vaccination Page 14 of 18 AlternativeAccommodations(listinorderofpreference): EffectiveDateofAccommodation: DurationPeriodofAccommodation: Documentreasondenyingrequestforareasonableaccommodation: ImmediateSupervisor ssignature: Date: DepartmentHead ssignature: Date: HR,EEOOfficerorDesignee: Date: CC:Employee DepartmentofHumanResources

15 Mandatory Influenza Vaccination Page 15 of 18 APPENDIX6B:JHUSAMPLERELIGIOUSACCOMMODATIONFORM RequestforExemptionfromInfluenzaVaccinationforReligiousReasons JohnsHopkinsUniversityiscommittedtodiversityandinclusivenessofallouremployees.JohnsHopkins Universityhasmandatedthatallpersonnelwhoprovidedirectpatientcareorworkinpatientcareareas bevaccinatedagainstinfluenza(theflu),forthe2011"2012fluseason.ifyouhavedeclinedtoreceive thefluvaccineforreligiousreasons,pleaseprovidethefollowinginformation: Name: Dateof Request: Department: ImmediateSupervisor: Becausethemandatoryvaccinationconflictswithmysincerelyheldreligiousbeliefsandpracticesor membershipinachurchorreligiousbody,ideclinetheinfluenzavaccinationatthistime. NameofReligiousBelief,ChurchorReligious Body: Signature: Date: ReligionTenet(s)Documentation Insomecases,JHUwillneedtoobtaindocumentationorotherauthorityregardingyourreligious practiceorbelief.wemayneedtodiscussthenatureofyourreligiousbelief(s),practice(s)and accommodationwithyourreligion sspiritualleader(ifapplicable)orreligiousscholarstoaddressyour requestforanexemption. Ifrequested,canyouobtaindocumentationorotherauthoritytosupporttheneedforanexemption basedonyourreligiouspracticeorbelief?yes No Ifno,explainwhy: VerificationandAccuracy IverifythattheaboveinformationiscompleteandaccuratetothebestofmyknowledgeandI understandthatanyintentionalmisrepresentationcontainedinthisrequestmayresultindisciplinary action. Ialsounderstandthatmyrequestforanexemptionmaynotbegrantedifitisnotreasonableorifit createsanunduehardshiponmyemployer. Signature: Date:

16 Mandatory Influenza Vaccination Page 16 of 18 Print Name: SummaryofNextSteps 1. ThisrequestwillbereviewedwithyouandacknowledgedbyHumanResources,Occupational HealthortheOfficeofInstitutionalEquity. 2. Youwillbenotifiedofthedecisionregardingyourrequestedexemption. 3. Ifyouaregrantedareligiousexemption,youmayberequiredtowearasurgicalmaskduring theinfluenzaseasonwhenworkingdirectlywithpatients,workinginpatientareas,orcoming within6feetofpatients. 4. Ifyoudisagreewiththedecisionregardingyourrequest,pleasecontacttheJHUOfficeof InstitutionalEquityforassistanceat410"516"8075.

17 Mandatory Influenza Vaccination Page 17 of 18 APPENDIX7:SAMPLENEWEMPLOYEEORIENTATIONACKNOWLEDGEMENT InfluenzaVaccinationRequirement TheJohnsHopkinsInstitutionsrequiresinfluenzavaccinationsimilartootherrequiredvaccinationssuch asmmrandvaricellaasaconditionofemploymentforallhealthcareworkers. Acknowledgement Ihavereceivedandreadacopyof[HSEPolicy#]requiringinfluenzavaccinationforallhealthcare workers. EmployeeName(Print) EmployeeSignature Date

18 Mandatory Influenza Vaccination Page 18 of 18 APPENDIX8:STATEMENTOFATTESTATIONFORM [Entity Letterhead] Influenza Vaccination Requirement I understand that Johns Hopkins University requires influenza vaccination similar to other required vaccinations such as MMR and varicella as a condition of employment for all its healthcare workers. Acknowledgement I have received and read a copy of Johns Hopkins University s Mandatory Seasonal Influenza Vaccination Policy requiring influenza vaccination for all healthcare workers, and agree to abide by it. Employee Name (Print) Employee Signature Date