Refusal to Receive Covid Vaccination

Cheyenne Regional Medical Center Occupational Health Department 2301 House Avenue, Suite 500A 307-633-7897/ Fax: 307-633-7737
Refusal to Receive Vaccination

Covid-19 Vaccination
Name*
First & Last Name
Date of birth*

MonthDayYear
Vaccination Declination:*

Covid-19
Please read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement(s):
- The purpose of and need for the recommended vaccines(s
- The risks and benefits of the recommended vaccines(s
- Cheyenne Regional Medical Center and the CDC Advisory Committee on Immunization Practices recommend the vaccines(s) be given to screened individuals who are determined to be candidates for the vaccines(s).
- Should I become infected, I understand failure to follow recommendations may endanger my health, and the health of others I may come in contact with.
- I understand I am not immune and if exposed to a disease, I may be furloughed during the period of potential infectivity.
- I am declining the recommended vaccine selected above.
- I acknowledge that I have read and under this document.
Signature*

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NOTICE:

Submitted documents will be sent to StudentResults@crmcwy.org for review
Witness
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Refusal to Receive Vaccination