VA Form 10-9050 is the Seasonal Influenza Vaccination Program form for Veterans Health Administration health care personnel. It documents one of three routes: receiving the seasonal influenza vaccine, requesting a medical exception or requesting a religious exception. The June 2026 form includes instructions for supporting evidence and signatures. This guide explains the documented audience, completion steps, supporting evidence, cautions and questions based on the official document and relevant agency instructions. Use the PDF resource to review and prepare the document; filing is governed by the agency’s rules.
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What is 10-9050?
VA Form 10-9050 is the Seasonal Influenza Vaccination Program form for Veterans Health Administration health care personnel. It documents one of three routes: receiving the seasonal influenza vaccine, requesting a medical exception or requesting a religious exception. The June 2026 form includes instructions for supporting evidence and signatures.
Who needs to file 10-9050?
The form is expressly for VHA health care personnel and provides employee/person categories for VHA employees, without-compensation appointees/volunteers and others.
When to file 10-9050
The June 2026 form states that personnel who do not receive the vaccine by November 30, or within two weeks of starting employment, must wear a face mask in accordance with VHA policy. This statement is a condition on the form; it is not presented here as a universal deadline for every employee.
Documents you need
- If vaccinated outside the EOH program: documented proof of vaccination submitted with VA Form 10-9050.
- For a medical exception: physician information, physician signature, date and NPI, plus supervisor confirmation as indicated by the form.
- For a religious exception: written notice to the immediate supervisor, as stated in option 3.
How to fill out 10-9050
Choose one program option
Select vaccinated, medical exception or religious exception; the form instructs you to choose one.
If vaccinated, identify the location
For option 1, specify whether vaccination was within EOH or outside EOH. Add documented proof if vaccination was outside EOH.
If requesting a medical exception
For option 2, follow the physician and supervisor fields; the form refers to CDC-recognized contraindications and precautions.
If requesting a religious exception
For option 3, confirm that you notified your immediate supervisor in writing and complete the supervisor confirmation.
Identify your personnel category
In the final section mark VHA employee, WOC appointee/volunteer, or other and explain other where applicable.
Complete your identification
Supply your printed name and date of birth in the final section.
Sign and date
Read the final acknowledgment and complete employee signature and date.
How to submit 10-9050
The form directs the person to select one option, complete the final section and sign. For vaccination outside the Employee Occupational Health (EOH) program, documented proof must accompany the form. The PDF does not supply a universally applicable public upload portal or mailing address.
Common mistakes to avoid
- Do not select multiple mutually exclusive options; the form says to select one.
- Do not omit proof of vaccination if claiming vaccination outside the EOH program.
- Do not forget the final employee/person type, identifying information, signature and date.
Frequently asked questions
Is vaccination proof always required?
No. Option 1 expressly says proof is not required for vaccinations within EOH, but it is required for vaccinations outside EOH.
Can this form be used for a medical exception?
Yes. Option 2 provides a medical-exception declaration and physician and supervisor fields.
Does the form support a religious exception?
Yes. Option 3 includes a religious-exception declaration and a written-notice statement.
Who signs the final section?
The employee/person completes the final acknowledgment, signature and date fields.
What is the form revision?
The extracted VA Form 10-9050 states June 2026.
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