Covid-19 Declination Form

My employer (or affiliated health facility), Kaiser Foundation Health Plan Inc, recommends that I receive COVID-19 vaccination to protect myself, patients, staff, and others in the healthcare facility.

I acknowledge that I am aware of the following facts:

  • COVID-19 is a serious contagious virus that can easily spread from person to person. Some infected persons may have severe disease and die. No one knows how COVID-19 may affect them.
  • COVID-19 vaccination is recommended for me and for all other healthcare workers to help prevent spreading the disease to friends, family, and staff and to protect me from getting COVID-19 or from serious illness if I do get infected.
  • I understand that, if I contract COVID-19, I am potentially contagious for 2 days before any symptoms appear. During this time, and for 10–14 days after infection, I can potentially transmit COVID-19 to patients and staff in this facility and to my family.
  • I understand that, if I become infected with COVID-19, even if my symptoms are mild or non-existent, I can spread the virus to others. Symptoms that are mild or non-existent in me can still cause serious illness and death in others.
  • I understand that, if I get COVID-19, I will be required to isolate away from others and will not be able to work for a minimum of 10 days after symptoms appear, or 10 days from the date I test positive if I have no symptoms.
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