COVID-19 Health Measure Declination Form
Please complete this form to formally decline participation in specified COVID-19 health measures. All information provided will be treated confidentially and used solely for declination documentation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Affiliation
Which COVID-19 health measure(s) are you declining?
*
Vaccination
Testing
Mask Wearing
Symptom Screening
Other
Please briefly state your reason(s) for declining the selected measure(s)
*
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Declination
Submit Declination
Should be Empty: