Free Employee Refusal of Medical Treatment Form Template

When employees refuse medical treatment, it can lead to legal complexities and health risks. This Employee Refusal of Medical Treatment Form Template helps you effectively document these situations, ensuring clarity and compliance. With our template, you can secure formal consent, protect your organization's liability, provide clear documentation for future reference, and maintain a professional relationship with your team. Additionally, it features WCAG-aligned labels to support accessibility needs. Start using the live template today to simplify your documentation process.

When to use this form

Use this form any time an employee declines on-site first aid, transport, or follow-up care after a workplace incident. It fits minor cuts, chemical splashes, needle sticks, post-exposure evaluations, or when someone turns down an employer-recommended clinic visit or vaccination. You get a clear record of what was offered, the risks explained, and the choice made. HR, safety leads, and supervisors gain consistent documentation for OSHA logs, return-to-work, and workers' comp. If the refusal involves immunizations, pair it with a Vaccine waiver form. For later sharing of records with a clinic, include a Medical authorization form. For vaccine-specific declinations, you can also use a Vaccine refusal form.

Must Ask Employee Refusal of Medical Treatment Questions

What happened, when, and where did the incident occur?
Time, location, and a short description link the refusal to a specific event. Clear details support OSHA logs, workers' comp, and internal investigations.
What evaluation, first aid, transport, or vaccinations were offered, and which are you refusing?
Listing each option shows that reasonable care was offered and what was declined. It reduces disputes later and guides what to offer next time.
What risks and possible consequences of refusing were explained, and do you understand them?
Documented risk counseling turns a simple no into an informed decision. It protects you and the employee by showing understanding and voluntary choice.
Are you able to make this decision today (alert, oriented, and not impaired)?
Capacity checks ensure the person can refuse safely; if not, pause and escalate. If the employee wants someone else to decide in the future, provide a Caregiver consent form.
Who witnessed this discussion and refusal (name, role, contact), and will you sign to confirm?
Witness and signature make the record credible and close the loop on consent. They also enable follow-up if symptoms worsen or circumstances change.

More Forms

Question		Response
Employee full name		John Smith
Job title		This is a test
Department or team		This is a test
Employee ID or number		This is a test
Phone number		555 555 5555
Work email		[email protected]
Incident date		2025-10-15T00:00:00.000Z
Incident time		This is a test
Incident location		This is a test
Brief description of the incident		This is a test
Describe the injury or affected area (if any)		This is a test
Current symptoms (if any)		This is a test
Did an injury or illness result from this incident?		Yes
Was medical evaluation or first aid offered by the employer?		Yes
What types of care were offered? (select all that apply)		Referral to occupational health provider
Name of provider or facility offered (if applicable)		This is a test
Did you receive any treatment before refusing?		No
I am voluntarily refusing the medical treatment offered at this time.		Agree
If other, please specify		This is a test
Refusal date		2025-10-15T00:00:00.000Z
Refusal time		This is a test
Primary reasons for refusing treatment (select all that apply)		Symptoms are mild or improving
I understand that refusing treatment may delay recovery or worsen my condition.		Neither agree nor disagree
I understand I can obtain medical care later and can notify my employer if my condition changes.		Agree
I have been informed how to report worsening symptoms and how to seek care if I change my mind.		Agree
I understand that I may still file a workers' compensation claim regardless of this refusal.		Agree
I had the opportunity to ask questions and received answers.		Strongly disagree
Witness full name		John Smith
Witness role or title		This is a test
Employer representative full name		John Smith
Employer representative title		This is a test
Will a follow-up check be scheduled?		No
Preferred contact method for follow-up		Phone call
Preferred contact time window		Morning (8am-12pm)
Employee signature		This is a test
Date signed by employee		2025-10-15T00:00:00.000Z
Witness signature		This is a test
Date signed by witness		2025-10-15T00:00:00.000Z
Employer representative signature		This is a test
Date signed by employer representative		2025-10-15T00:00:00.000Z

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Employee Refusal of Medical Treatment Form Template

Ensure Clarity and Compliance with Our Employee Medical Refusal Form

When to use this form

Must Ask Employee Refusal of Medical Treatment Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

Employee Refusal of Medical Treatment Form Template

Ensure Clarity and Compliance with Our Employee Medical Refusal Form

When to use this form

Must Ask Employee Refusal of Medical Treatment Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results