Form for Refusal to Receive Covid Vaccine

Refusal to Receive COVID-19 Vaccination

Employee's name *

First

Last

Date of birth *

Email *

Description:

I have been advised per CDC and NYSDOH that I should receive the following vaccines: COVID-19 Vaccine

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement(s) explaining the vaccine(s) and the disease(s) they prevent located throughout the webpages:
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html and https://covid19vaccine.health.ny.gov/.

I have had the opportunity to discuss the statements and have my questions answered by a healthcare provider. I understand the following:

• The purpose of the need for the recommended vaccine.

• The risks and benefits of the recommended vaccine.

• I understand that I cannot get COVID from the vaccine.

_____________________________________________________________________________

Nevertheless, I have decided to decline the vaccine above. My reason for declining the vaccine is:

Reason (please choose only one) *

My doctor certifies that immunization with COVID-19 vaccine is detrimental to my health. PROVIDE LETTER/NOTE FROM YOUR DOCTOR AND FAX TO 631-261-5750.
Religious Reasons

_____________________________________________________________________________

I know that failure to follow the recommendations about vaccination may endanger my health, and the health of others I may come in contact with should I become infected.

I know that I may re-address this issue with my health care provider at any time and accept vaccination in the future.

I acknowledge that I have read this document in its entirety and fully understand it.

Employee's Signature *

Date *