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Covid-19 Vaccination Consent & Declination

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16 views2 pages

Covid-19 Vaccination Consent & Declination

Uploaded by

sanskari.mayank200017
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CYNET HEALTH

COVID-19 VACCINATION CONSENT/DECLINATION FOR STAFF

Employee Demographics

Last Name: ________________________ First Name: __________________ Middle Name: _______________

Gender: Female Male Date of Birth: _________________

Direct patient contact: Yes No Department: _________________ Job classification: ______________

Vaccination and Declination Details

Type of vaccination: COVID-19

Consent:
I have been given a copy and have read and have had explained to me the COVID-19 Vaccine EUA Fact Sheet
I hereby consent to the administration of the COVID-19 vaccine.

Date: ____________________ Employee Signature: ________________________________

I have had the COVID-19 vaccine administered to me at another facility. Supply documentation

Declination:
I hereby decline the administration of the COVID-19 vaccine for the following reason(s):
Check reason:

Medical Reasons

Religious Reasons

Other __________________

I have received education about the effectiveness of COVID-19 vaccination as well as adverse events. I have been given the
opportunity to be vaccinated at no charge to myself.
I understand that by declining this vaccine. I continue to be at risk of acquiring COVID-19, potentially resulting in the transmission to
others, particularly in persons at high risk for COVID-19 even when I have no symptoms.
I also understand that I will be required to wear a mask at all times when at work, including in the breakroom.

Date: ____________________ Employee Signature: ________________________________


For office use only
Vaccine: __________________________ Brand of vaccine: __________________________

Lot # _________________ Expiration Date: ______________________________

First Vaccine Second Vaccine

Route of administration: Intramuscular Site: L Deltoid R Deltoid

Date: ___________________________ Vaccinator signature: _________________________________

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