Can this form be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention are met.

Is HIPAA relevant here?

If the form contains protected health information, HIPAA applies; use a BAA with vendors and retain records per HIPAA rules (45 CFR §164.530(j)).

Do I need a notary or witness?

Most declination forms do not require notarization, but some states or specific exemption affidavits may; check state rules and employer policy before requiring notarization.

What if an employee changes their mind?

Document the revocation or new consent with a dated, signed statement; update the personnel and health records and follow employer procedures for immunization changes.

How long should we keep the form?

Retain while employment or care relationship is active and for at least six years for HIPAA-related records; follow IRS and state retention requirements where applicable.

What if the form is incomplete?

Return incomplete forms for correction; incomplete or unsigned declinations may be treated as no declination and could expose the organization to disputes or compliance issues.

Electronic Signature
Templates
Healthcare
Healthcare COVID Declination Form

Healthcare COVID Declination Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare COVID Declination Form

I acknowledge that I have been offered the COVID-19 vaccine and/or COVID-19 testing and that the benefits, risks, and alternatives have been explained to me. Patient Name: Date of Birth: Medical Record / ID:

Patient Information

Full Legal Name Date of Birth Gender Address

Primary Phone

Email

Emergency Contact (Name and relationship) Emergency Contact Phone

Insurance Information

Insurance Provider

Policy / Member ID

Group Number

Subscriber Name (if different)

Medical History (Relevant)

Current Medications Allergies (including vaccine or medication reactions) Prior Surgeries / Significant Medical History Chronic Conditions

Declination Details

Vaccine/Test Offered: COVID-19 vaccine COVID-19 testing Date Offered:

Staff Member Who Offered (Name and Title)

I acknowledge that the benefits and risks associated with receiving the COVID-19 vaccine/testing were described to me, including the potential health risks of declining. I have had an opportunity to ask questions and have received answers I understand.

I understand that by declining the COVID-19 vaccine/testing I may be at increased risk of contracting and spreading COVID-19, and that this could have consequences for my personal health and for those around me, including family members and other patients.

Reason(s) for Declination (check all that apply)

Personal preference Concern about medical risks or allergies Religious or moral objection Recent COVID-19 infection / recovery Other (please specify)

Acknowledgment of Alternatives and Future Consent

By signing below I acknowledge that I may change my decision at any time. I understand that if I later consent to vaccination or testing I will be asked to complete the standard consent for that service.

Declination Effective Until

This declination remains in effect until: or until I revoke this declination in writing.

Privacy and Acknowledgment

I acknowledge that my medical information related to vaccination/testing may be recorded in my medical record and shared with public health authorities as required by law. I have been provided the facility's privacy practices.

Privacy Acknowledgment I acknowledge receipt of privacy practices and understand the handling of my health information.

Staff Attestation

Staff attests that the COVID-19 vaccine/testing was offered, risks and benefits were explained, and questions were responded to:

Staff Printed Name and Title Staff Date of Attestation

By signing below, I confirm that I understand the information provided, that I refuse the COVID-19 vaccine and/or testing at this time, and that I release the facility from obligation to provide the vaccine/testing unless I later request it. This declination does not waive any legal rights nor does it create any contractual obligation beyond the acknowledgments stated herein.

Patient Name:

Signature:

Date:

If signed by guardian, relationship to patient:

If signed by guardian, guardian printed name:

What the Healthcare COVID Declination Form Is and when it's used

A Healthcare COVID Declination Form documents an individual’s decision to refuse a COVID-19 vaccine, booster, or related clinical intervention offered by a healthcare employer or provider. The form records the signer’s identity, date, explicit declination statement, and any stated reason or exemption type (medical, religious, or other). Organizations use the form to demonstrate that an informed refusal occurred, to track workforce vaccination status, and to support workplace health and safety procedures while maintaining a record for regulatory or employment review.

Why this declination form matters for compliance and records

A clear declination form reduces ambiguity about consent, creates an auditable record for employers and health systems, and helps manage exposure controls and accommodation workflows while documenting the individual’s informed refusal.

Who typically completes or manages the Healthcare COVID Declination Form

Typical participants include the employee or patient who declines, an HR or occupational health representative, and sometimes a supervising clinician or manager.

Employees and contractors who decline vaccination and need an official record of their decision for employer files.
Occupational health staff and HR administrators who process declinations, evaluate accommodations, and retain documentation.
Clinical supervisors and risk managers who need a signed record to support workplace safety protocols.

Properly completed forms support legal defensibility, consistent accommodation processes, and administrative tracking of immunization status.

Stepwise process for completing this form

Follow these four practical steps to complete, document, and route a Healthcare COVID Declination Form correctly.

01

Review policy: Confirm employer policies and available exemptions before completing the form.
02

Complete fields: Enter required personal and declination details accurately.
03

Sign and date: Provide signature and date to confirm informed refusal.
04

Route to HR: Submit to designated occupational health or HR inbox for filing.

Essential elements to include in a professional declination form

A properly structured form combines identity verification, explicit declination language, reason categorization, acknowledgment of information provided, signature, and routing instructions to be useful for employers and compliance teams.

Identity block

Full legal name, date of birth, employee ID or patient number, and preferred contact details to reliably identify the signer.

Clear declination statement

A short, unambiguous sentence stating the individual declines the COVID-19 vaccine or booster offered at this time.

Exemption category

Checkboxes for medical, religious, or other reasons plus space for brief explanation and any supporting documentation.

Informed acknowledgement

Language confirming the signer received information about risks, benefits, and workplace implications before refusing.

Signature block

Printed name, handwritten or electronic signature, date, and space for a witness or verifier if required.

Filing instructions

Designated routing steps including submission method, department to receive the form, and retention classification.

Required data fields summary

Name: Full legal name

Date: MM/DD/YYYY

Identifier: Employee or patient ID

Declination: Explicit refusal statement

Reason: Exemption category

Signature: Signed and dated

Digital signing and submission options

Use secure eSignature platforms that support audit trails, data encryption, and optional advanced authentication when collecting declination forms electronically.

Basic eSign: Email link signing
Advanced auth: SMS or KBA verification
Audit trail: IP, timestamp, log

Choose a platform with HIPAA support (BAA available) if the form will contain protected health information; ensure encrypted storage and role-based access controls for retained records.

Where to send or file a completed declination form

After signing, route the form per employer or facility instructions. Typical destinations include occupational health, HR records, or a secured compliance repository.

Occupational health: Primary clinical record location
Human resources: Employee personnel file
Secure archive: Encrypted document storage
Supervisor: Manager notification when required

How to set up an online declination workflow

Configure a consistent digital workflow so completed forms are automatically routed, stored, and logged for compliance reviews.

Field	Configuration
Identity fields	Mandatory, validate format
Declination checkbox	Required, single-select
Signature	eSign field with timestamp
Destination	Auto-route to HR/Health

Timelines to process and review declination forms

Establish internal deadlines for acknowledgement, accommodation assessment, and record retention to ensure consistent handling.

Submission deadline:

Provide form upon initial offer or request

HR acknowledgement:

Acknowledge within 7 business days

Accommodation review:

Complete assessment within 14 days

Follow-up testing:

Schedule as required by policy

Retention start:

Retention begins on signature date

Common mistakes to avoid when preparing the form

Using an unsigned or undated form that leaves the timing of declination ambiguous and weakens the record.
Failing to capture the signer’s legal name or employee identifier, causing mismatches in personnel or medical systems.
Storing completed forms in unsecured email or personal drives instead of encrypted HR or health record systems.
Omitting required acknowledgment language about risks and potential workplace implications before signature.

Risks and compliance consequences of incomplete or incorrect forms

Employment risk: Disciplinary action possible

Record disputes: Challengeable in grievance

HIPAA exposure: Improper handling risks breach

Legal liability: Potential litigation risk

Operational impact: Policy gaps affect staffing

Regulatory review: Auditors may request records

Real-world examples of declination form use

Two concise examples show typical contexts where a signed declination form supports HR and clinical processes.

Hospital staff declination

A nurse declines a booster due to a medical condition and submits a signed declination including a clinician note

Employer logs the form in occupational health
The record enables scheduled testing protocols and documents the accommodation request for audit purposes.

University employee declination

A campus technician declines vaccination for religious reasons and completes the institutional declination form

HR reviews and requests supporting documentation if required
The signed form is filed in the personnel record and used to determine testing cadence and remote-work eligibility.

Comparison: common eSignature providers for declination forms

Basic pricing and feature availability for commonly used eSignature platforms. signNow appears first in the table per vendor ordering rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about declination forms

Answers to common operational, legal, and technical questions about using and storing Healthcare COVID Declination Forms.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention are met.
Is HIPAA relevant here?
If the form contains protected health information, HIPAA applies; use a BAA with vendors and retain records per HIPAA rules (45 CFR §164.530(j)).
Do I need a notary or witness?
Most declination forms do not require notarization, but some states or specific exemption affidavits may; check state rules and employer policy before requiring notarization.
What if an employee changes their mind?
Document the revocation or new consent with a dated, signed statement; update the personnel and health records and follow employer procedures for immunization changes.
How long should we keep the form?
Retain while employment or care relationship is active and for at least six years for HIPAA-related records; follow IRS and state retention requirements where applicable.
What if the form is incomplete?
Return incomplete forms for correction; incomplete or unsigned declinations may be treated as no declination and could expose the organization to disputes or compliance issues.

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