VA Form 10-9050: Influenza Vaccination Form Download – VA Form 10-9050 is the official Health Care Personnel Influenza Vaccination Form required for Veterans Health Administration (VHA) healthcare personnel. It documents compliance with the mandatory seasonal influenza vaccination program or approved exemptions.
This article explains everything USA-based VA employees, volunteers, trainees, and other healthcare personnel need to know about the form, requirements, deadlines, and how to complete it correctly.
What Is VA Form 10-9050?
VA Form 10-9050, titled Health Care Personnel Influenza Vaccination Form, is a one-page document used by VHA facilities to track seasonal flu vaccination status among healthcare personnel (HCP).
It serves as official documentation that individuals have either:
- Received the current season’s influenza vaccine, or
- Received an approved medical or religious exemption.
The form is part of VHA Directive 1192.01, which establishes a mandatory seasonal influenza vaccination program for all VHA healthcare personnel. Compliance is a condition of employment or affiliation with VA facilities.
Who Must Complete VA Form 10-9050?
The form applies to:
- VA employees
- Volunteers
- Trainees, residents, interns, fee-basis staff, and researchers
- Other healthcare personnel working in VHA facilities who provide or support patient care
It ensures high vaccination rates to protect vulnerable veterans and staff from seasonal influenza.
Administrative staff or those not involved in healthcare-related duties may have different requirements—check with your supervisor or Employee Occupational Health.
Why Is the Influenza Vaccination Required for VA Healthcare Personnel?
VHA policy prioritizes patient safety and infection control. Annual flu vaccination reduces the spread of influenza in healthcare settings, where patients are often at higher risk of complications.
Key benefits include:
- Protecting veterans, coworkers, and yourself
- Meeting CDC recommendations for healthcare personnel
- Maintaining compliance with federal workplace safety standards
For the 2025-2026 flu season, updated trivalent vaccines are recommended for all persons aged 6 months and older without contraindications.
How to Download VA Form 10-9050 (Fillable PDF)?
You can download the official fillable version directly from the VA website:
Download VA Form 10-9050 Health Care Personnel Influenza Vaccination Form (Fillable PDF)
The form is updated periodically—always use the latest version from the official VA source.
Step-by-Step Guide: How to Fill Out VA Form 10-9050?
- Identify Your Role — Check the appropriate box: Employee, Volunteer, or Other (specify if Trainee, etc.).
- Choose One Statement:
- Vaccinated: Check the box and attach proof of vaccination (e.g., record from pharmacy or VA clinic).
- Medical Exemption: Provide details of CDC-recognized contraindication. Requires physician signature, name, address, date, and NPI number.
- Religious Exemption: Notify your supervisor in writing about deeply held beliefs.
- Provide Signatures — Include your printed name, last 4 of SSN, department, signature, and date. Supervisor signatures are required for exemptions.
- Submit the Form — Employees and volunteers submit to Employee Occupational Health. Trainees submit to the Designated Education Officer. Secure electronic submission is allowed.
Deadline: Typically by November 30 each year, or within two weeks of starting employment/affiliation.
Medical and Religious Exemptions on VA Form 10-9050
Medical Exemption — Must be based on recognized CDC contraindications or precautions. A physician must acknowledge the contraindication.
Religious Exemption — Requires written notification to your immediate supervisor about a sincerely held religious belief. No additional documentation form is needed beyond VA Form 10-9050.
Important: Individuals with exemptions must wear a face mask according to VHA guidelines and may face other requirements. Non-compliance can lead to disciplinary action.
What Happens After Submitting VA Form 10-9050?
Employee Occupational Health tracks compliance. Facilities monitor rates and report to leadership. High compliance supports a safer environment for veterans.
If vaccinated at a non-VA location, attach proof of vaccination to the form.
Common Questions About VA Flu Vaccination Requirements
Is the flu shot mandatory for VA employees?
Yes, under VHA Directive 1192.01, it is mandatory unless a valid medical or religious exemption is approved.
Where can I get the flu vaccine?
VA facilities often provide it on-site at no cost. You can also use community pharmacies, clinics, or your primary care provider.
Do I need a new form every year?
Yes — the form is for the current flu season only.
What if I decline the vaccine?
You must complete the declination/exemption section, follow masking and other protocols, and understand potential consequences.
Stay Protected This Flu Season
Getting vaccinated and properly documenting it with VA Form 10-9050 is a critical part of VA healthcare culture. It protects patients, colleagues, and the broader veteran community.
For the most current guidance:
- Visit your local VA facility’s Employee Occupational Health office
- Review VHA Directive 1192.01
- Consult the CDC Influenza Page
Official Download:
VA Form 10-9050 Fillable PDF
This information is based on official VA sources and current as of 2026. Always verify with your facility for the latest requirements.