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COVID-19 Vaccine Declination Form Template

Streamline the process of documenting vaccination refusals

If you need to document someone's choice to decline the COVID-19 vaccine, this form template is here to help you simplify that important process. Designed for healthcare providers and employers, it enables you to capture essential information regarding an individual's vaccination refusal clearly and efficiently. With this straightforward template, you can ensure compliance, maintain accurate records, and streamline your administrative tasks, all while providing a user-friendly experience. Explore how easy it is to customize and use the live template today.

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Full name
Date of birth
Employee or patient ID
Organization or employer
Department or unit (if applicable)
Email address
Phone number
Have you received any dose of a COVID-19 vaccine?
Yes
No
Date of most recent COVID-19 vaccine dose (if applicable)
I am declining to receive a COVID-19 vaccine at this time.
Yes
No
Reason(s) for declination (select all that apply)
Please Specify:
If you selected Other, please describe
Are you requesting a formal accommodation or exemption from your organization?
Yes
No
I understand that COVID-19 can cause serious illness and that vaccination can reduce the risk of severe disease.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand that by declining, I may be at increased risk of acquiring or transmitting COVID-19.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand I may be required to comply with additional safety measures as directed by my organization.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand that I can change my decision at any time and choose to receive a vaccine in the future.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Relationship to the individual (if signing on behalf of someone else)
Signature of decliner or authorized representative
Date signed
I certify that the information provided in this form is true and complete.
True
False
Received by
Title or role
Date received
Record location or notes
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Date of birth, Employee or patient ID","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a flu shot proof form for FormCreatorAI article.

When to use this form

Use this template when you must document an employee, contractor, student, or volunteer choosing not to receive a COVID-19 vaccine. It helps HR, clinic managers, and school admins capture reasons, confirm awareness of risks, and record agreement to follow safety measures like masking or testing. Use it during onboarding, annual compliance, or outbreak response, so you have a consistent record for audits and accommodations. If someone later chooses vaccination, point them to the COVID-19 Vaccine consent form. For flu season, send your staff the Influenza declination form instead, and for other shots use the Vaccine refusal form. If you offer remote counseling about vaccine decisions, pair this with a Telehealth consent form.

Must Ask COVID-19 Vaccine Declination Questions

  1. What is your primary reason for declining the COVID-19 vaccine?

    Knowing the reason helps route requests (medical, religious, or personal) and determine documentation needs. It also guides appropriate accommodations and clear follow-up steps.

  2. Have you received any prior COVID-19 vaccine doses (product and date)?

    Dose history clarifies whether this is a deferral, a partial series, or a full refusal. It improves clinical accuracy and reduces back-and-forth later.

  3. Do you acknowledge the risks of remaining unvaccinated, including higher risk of infection and transmission?

    An informed acknowledgment supports ethical, compliant decision-making and protects your organization. If someone wants counseling before deciding, you can schedule a visit and use the Telehealth consent form.

  4. What is your role and level of exposure risk (patient-facing, public-facing, or remote)?

    Job risk helps you assign safeguards like testing cadence, PPE, or reassignment. It also documents why different measures apply to different roles.

  5. If your reason is medical, can you provide documentation from a licensed clinician?

    Verification speeds up accommodation reviews and ensures the record meets policy and regulatory needs. Clear criteria reduce disputes and help you apply policies consistently.

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