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Flu Vaccine Declinations for Healthcare Workers

Each fall, facilities may ask staffing agencies for each worker's flu shot record, or a signed declination. CDC recommends a flu vaccine every season for health care personnel. But the rules about declining, masking, and proof come from states and facilities. This guide explains the CDC recommendation, how declinations work, what some facilities must report to the federal government, and where state law comes in.

Updated October 3, 2026 · Checked against the official sources listed at the end

What CDC recommends

CDC's 2011 report on immunizing health care personnel recommends flu vaccination for all health care personnel who have no contraindications. It stresses that this means all health care personnel, not just those with direct patient care duties. It recommends vaccination every year with the current season's vaccine.

CDC's definition of health care personnel is broad. CDC's current flu guidance lists nurses, nursing assistants, therapists, technicians, and other staff. It also lists "contractual staff members." That includes agency staff.

For the current season, CDC's flu vaccine page (updated September 1, 2026) says that, because of legal uncertainties and inquiries, the flu vaccine recommendations from the July 2025 immunization schedule remain in effect for the 2026-2027 season.

Timing: CDC says that for most people who need one dose, vaccination should ideally be offered in September or October.
Cost: CDC's 2011 report says facilities that employ health care personnel should provide flu vaccine at no cost to them.
CDC recommends. States and facilities decide what is required. CDC's 2011 report notes that several states and facilities have set their own requirements.

How declinations work

A declination is a signed form saying the worker was offered the flu vaccine and chose not to get it. Declination forms come from facility policy or state rules.

CDC's 2011 report says some institutions have adopted signed declinations. It also says declination programs alone have not been shown to push coverage above 70 to 80 percent. CDC says institutions that require declinations should educate and counsel those workers about the benefits of the vaccine.

CDC's infection control guidance for flu lists strategies some institutions use. These include free vaccine, easier access at work, declination forms that confirm the worker was educated about benefits and risks, and requiring vaccination for all health care personnel without a contraindication.

Use the facility's own declination form when it has one.
Get a new signed form each flu season.
Keep the signed, dated form in the worker's file.
Ask the facility what it requires from workers who decline, such as wearing a mask.

Masking during flu season: the New York example

Some facilities ask unvaccinated workers to wear a mask during flu season. In New York, this is required by state regulation.

New York's rule (10 NYCRR 2.59) covers hospitals, nursing homes, diagnostic and treatment centers, home care agencies, and hospices. During flu season, these facilities must make sure that personnel not vaccinated for the current season wear a surgical or procedure mask in areas where patients or residents are typically present. Facilities must supply the masks at no cost. The rule also lets facilities adopt stricter policies.

In this rule, "flu season" means the period when the state Health Commissioner determines flu is prevalent. The New York State Department of Health says that as of April 23, 2026, flu is no longer prevalent in the state, so the mask requirement is not in effect for now. Check the Department's page for the next declaration.

New York's rule defines personnel to include contract staff.
Outside New York, ask each facility whether it has a masking policy for workers who decline.

Proof for agency staff in New York

New York's rule requires facilities to document the flu vaccination status of all personnel for the current season. The proof must be one of a few kinds.

For workers employed by another healthcare employer, such as a staffing agency, the rule accepts an attestation from that employer. The attestation must say the named workers have been vaccinated for the current season and that the employer keeps the vaccination documentation.

A document from the licensed practitioner who gave the vaccine. It must show that one dose was given, the vaccine formulation, and the date.
Or, for agency staff, an employer attestation as described above, backed by the practitioner documents in your files.
The Department also publishes a declination statement and a medical exemption statement for health care personnel.

What facilities report to CMS through NHSN

Certain facilities certified by the Centers for Medicare and Medicaid Services (CMS) must report health care personnel flu vaccination data through CDC's National Healthcare Safety Network (NHSN). NHSN's FAQ, updated January 27, 2026, lists acute care facilities, inpatient rehabilitation facilities, critical access hospitals, long-term acute care facilities, PPS-exempt cancer hospitals, and skilled nursing facilities. IRF units inside certain hospitals must report too.

CMS requires three groups: employees, licensed independent practitioners (non-employee physicians, advanced practice nurses, and physician assistants), and adult students, trainees, and volunteers. Contracted physicians, advanced practice nurses, and physician assistants count as licensed independent practitioners. Other contract personnel, like agency nurses, can be reported in an optional category but are not required by CMS.

The reporting period runs October 1 through March 31. For the 2025-2026 season, data had to be entered in NHSN by May 15, 2026. Facilities report summary counts, not data on each worker.

Vaccinated somewhere else: NHSN requires written proof. A signed statement, form, or email from the worker saying when and where, or a note, receipt, or vaccination card from the place that gave it, is acceptable. A verbal statement is not.
Declined: no documentation is required for NHSN reporting. A verbal statement is acceptable.
Medical contraindication: NHSN counts only a severe allergic reaction to the vaccine or its components, or Guillain-Barre Syndrome within 6 weeks after a previous flu shot.
Any other reason, including a religious exemption or a medical exemption the facility allows, is counted as "declined" for NHSN.

Other state laws

Some states have their own laws on flu vaccination for healthcare workers. CDC's 2011 report notes that several states have set requirements for checking vaccination status or giving vaccines to health care personnel.

One example is California. Its Health and Safety Code section 1288.7 says each general acute care hospital must offer onsite flu vaccine each year to hospital employees at no cost, if available. It also says the hospital must require employees to be vaccinated or to declare in writing that they declined. The law refers to hospital employees, so ask each hospital how it applies its policy to agency staff.

CDC keeps a database of state immunization laws for healthcare workers. CDC notes it was last updated in November 2014, so confirm current rules with your state.

Check the law in each state where you place workers.
Check each facility's policy. It may be stricter than state law.

What to keep in each worker's file

Keep one record per flu season. The record should hold up for the facility, for any state rule, and for the facility's NHSN reporting.

Season (for example, 2026-2027).
If vaccinated: date, where it was given, and a written record from the provider (vaccine formulation if available).
If declined: the signed, dated declination form for this season.
If a medical exemption is claimed: the facility's or state's exemption form, signed as required.
Any facility masking or other conditions the worker agreed to.
The date you sent proof or an attestation to each facility.

Common questions

Does CDC require healthcare workers to get a flu shot?

CDC recommends annual flu vaccination for all health care personnel without contraindications. It does not set facility requirements. States and facilities decide what is required, and CDC's 2011 report notes that several have done so.

Which CDC flu recommendations apply this season?

CDC's flu vaccine page, updated September 1, 2026, says the recommendations from the July 2025 immunization schedule remain in effect for the 2026-2027 season.

An agency nurse got a flu shot at a pharmacy. What proof do we need?

Get a written record. For NHSN reporting, a facility needs written proof for anyone vaccinated outside the facility, such as a receipt, vaccination card, or signed statement saying when and where. A verbal statement does not count.

Do hospitals have to report agency nurses to NHSN?

Not for CMS. NHSN's FAQ says CMS requires employees, licensed independent practitioners, and adult students, trainees, and volunteers. Other contract personnel can be reported in an optional category. Contracted physicians, advanced practice nurses, and physician assistants must be reported as licensed independent practitioners.

Does a religious exemption count as a medical contraindication for NHSN?

No. NHSN counts only two medical contraindications. A worker who does not get the vaccine for any other reason, including a religious exemption, is counted as declined.

When does New York's flu mask rule apply?

Only when the state Health Commissioner has declared flu prevalent. The Department of Health says that as of April 23, 2026, flu is no longer prevalent, so the mask requirement is not in effect for now. Check the Department's page for updates.

Sources

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