1 CDC – The Importance of COVID-19 Vaccination for ...



[Facility logo]Declination of COVID-19 VaccinationThe Centers for Disease Control1, the Minnesota Department of Health2, the Advisory Committee on Immunization Practices3, and [NAME of FACILITY] have recommended that I, as a long-term care health care worker, receive the COVID-19 vaccination to protect myself, the residents I care for, my friends, and those I live with. I acknowledge that I have been informed of the following facts:COVID-19 is a serious respiratory disease that has killed over 400,000 US citizens and over 2,000,000 people worldwide since the beginning of 2020.A COVID-19 vaccination is recommended for all workers in long-term care to prevent COVID-19 disease and its complications, including death.I have been informed that if I contract COVID-19, it is likely I will shed the virus for 24-48 hours before any COVID-19 symptoms appear. Shedding the virus can spread COVID-19 infection to others in this facility and in my home and community.I cannot get COVID-19 from the vaccine, as it is not a live vaccine.The COVID-19 vaccine contains no egg and no preservativeThe vaccine is being offered to me free-of-chargeThe vaccine being offered to me has been approved for emergency use by the FDACOVID-19 vaccines are carefully evaluated in clinical trials and are only authorized or approved if they make it substantially less likely I will get COVID-19 and the known and potential benefits of a COVID-19 vaccine must outweigh the known and potential risks of the vaccine for use.The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including: Residents in this facilityOther staff working at this facilityMy familyMy friends and others in the community ¨ I am choosing to decline the COVID-19 vaccination at this time. I understand that by declining this vaccine I continue to be at increased risk of acquiring COVID-19. I understand that I may change my mind at any time and accept the COVID vaccination if and when the vaccine is available. ¨ I have received the vaccine elsewhere (please indicate where and provide proof of vaccination)I have read and fully understand the information on this declination form. Signature: __________________________________________________ Date:____________ Name (print): ______________________________________ 1 CDC – The Importance of COVID-19 Vaccination for Healthcare Personnel 2MDH – Minnesota Guidance for Allocating and Prioritizing COVID-19 Vaccine – Phase 1a? 3APIC - Evidence Table for COVID-19 Vaccines Allocation in Phase 1a of the Vaccination Program ................
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