VA Form 10-9050: Health Care Personnel Influenza Vaccination Form
VA Form 10-9050 documents the seasonal influenza vaccination status of VA health care personnel, recording either receipt of the vaccine or a declination.
This is the genuine VA PDF, unmodified. Source: VA official page.
What is VA Form 10-9050?
VA asks its health care personnel to be vaccinated against seasonal influenza each year to protect patients and staff. This form is the standard record of that decision: it captures the individual's information and whether they received the vaccine, at VA or elsewhere, or declined it.
The completed form goes into the occupational health record at the employee's facility. Personnel who were vaccinated outside VA typically use it to document the outside vaccination, and those who decline acknowledge the associated education and any facility policies, such as masking requirements during flu season.
Who files VA Form 10-9050?
- VA employees working in health care settings during flu season
- Trainees, contractors, and volunteers covered by a facility's health care personnel vaccination policy
- Personnel documenting a flu vaccination they received outside VA
- Personnel declining the seasonal influenza vaccine who must record that declination
How to fill out VA Form 10-9050
- Enter your name, identifying details, and your facility or service information.
- Indicate whether you received the influenza vaccine this season, and where, or that you decline it.
- If vaccinated outside VA, note the date and provider so occupational health can record it.
- Sign and date the form.
- Return it to your facility's occupational health office or as directed by your supervisor or local policy.
Quick fill VA Form 10-9050 on this page
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Frequently asked questions
Who needs to complete VA Form 10-9050?
Health care personnel at VA facilities, which can include employees, trainees, contractors, and volunteers, depending on the facility's policy. Your occupational health office can confirm whether it applies to your role.
What happens if I decline the flu vaccine?
The form records your declination, and facility policy determines any additional steps, such as wearing a mask in patient care areas during flu season. Ask your occupational health office about your facility's current requirements.