COVID-19 Vaccine Declination Form

COVID-19 Vaccine Declination Form
My employer or affiliated health facility, St. Anthony Regional Hospital, has recommended that I am up-to-date with the Covid-19 vaccine in order to protect myself and the patients I serve.

I acknowledge that I am aware of the following facts:
- COVID-19 vaccination is recommended for me and all other healthcare workers to prevent COVID-19 and its complications, including death.
- If I become infected with COVID-19, even if I am asymptomatic or my symptoms are mild, I can still spread severe illness to others.
- I cannot get infected with the COVID-19 virus from the COVID-19 vaccine.
- The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including:
  - patients in this healthcare setting
  - my coworkers
  - my family
  - my community
Despite these facts, I am choosing to decline the Covid-19 vaccination at this time.
I understand that I may change my mind at any time and accept Covid-19 vaccination, if vaccine is available.
I have read and fully understand the information on this declination form.
By typing your full name, you attest to the validation of your responses above:
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