Resident Covid-19 Vaccine Declination Form

Form 9 of 9

Note: Fields marked with an * indicates required field

Resident: *

I acknowledge that I have read, or had explained to me, the Coronavirus Disease (COVID-19) General Information handout and the Emergency Use Authorization (EUA) Fact Sheet regarding the COVID-19 vaccine.

I have had the opportunity to ask questions, which have been answered to my satisfaction and understand the benefits and risks of the vaccination as described.

I understand that if I decline the vaccine, I may change my mind and request to be vaccinated at a later date, with the understanding that the vaccination will be based on the availability of the COVID-19 vaccine at that time.

I wish to refuse the COVID-19 vaccination (or refuse for the person named above for whom I am authorized to make this request). I understand that I may change my mind and request to be vaccinated later.

Resident Name: *

Resident/Responsible Person Signature Name: *

Date: *

If VERBAL DECLINATION was received for the resident:

Print name of person providing verbal declination:

Staff Member Signature (person who received verbal declination):

Date: