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:

  1. Covid-19 vaccination is recommended for me and all other healthcare workers to prevent Covid-19 and its complications, including death.
  2. 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.
  3. I cannot get infected with the Covid-19 virus from the Covid-19 vaccine.
  4. 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

By typing your full name, you attest to the validation of your responses above: