COVID-19 Vaccination Declination Statement

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COVID-19 Vaccination 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. *

Decline

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:

Type First and Last Name *

Department Name *

Enter Today's Date *