I have received a recommendation for COVID-19 vaccination to protect myself, my family, and other persons with who I may be working or residing.
I understand that COVID-19 has caused a pandemic that involves risk to the health and life of individuals.
I understand that in the absence of vaccination, I may acquire COVID-19 that may put my family, colleagues, friends, or persons around me at risk resulting in fatal consequences such as illness, disability, or death when exposed.
In light of these matters, I have received information or educational materials with regard to the vaccine against COVID-19. I have had the opportunity to ask questions and the answers were explained to me to my satisfaction. I understand that COVID-19 is a serious respiratory disease that has caused death globally. In case I have been exposed to an individual with COVID-19, I may be infected with it as well and spread the virus to the people around me.
However, it is my decision to decline the vaccination at this time, regardless of the information that I have received about its importance and the risk of not receiving it. I understand the consequences of my decision, including the continuity of risk of endangering my health and of others from being infected due to COVID-19. I understand that I may return anytime for receiving a vaccination, should I decide to receive it in the future as to its availability.
By signing this form, I hereby declare and acknowledge that I have read and fully understand the information on this declination form.