Healthcare Vaccination Policy

HEALTHCARE VACCINATION POLICY ACKNOWLEDGMENT AND CONSENT

Facility Name:   Effective Date:

Purpose and Scope

This Vaccination Policy establishes the facility's requirements for immunization of patients, staff, contractors, and volunteers to protect patient safety and maintain a safe care environment. The policy applies to all persons providing or receiving care at the facility unless an approved exemption or accommodation is granted under applicable law.

Definitions

Patient/Employee: any person receiving care or providing services at the facility. Vaccination Record: documentation, immunization card, or electronic record evidencing administration and date of vaccine. Exemption: documented medical or religious reason approved under facility procedure.

Patient / Employee Information

Insurance Information

Medical History

Required and Recommended Vaccinations

The facility requires or recommends the following vaccinations. Check all that apply to your vaccination history and indicate intent where requested:

Influenza (seasonal) — Date administered:

COVID-19 (primary and boosters) — Date administered:

Hepatitis B — Date administered:

MMR (Measles, Mumps, Rubella) — Date administered:

Varicella (Chickenpox) — Date administered:

Tdap (Tetanus, Diphtheria, Pertussis) — Date administered:

Other: — Date:

Documentation and Recordkeeping

Individuals must provide acceptable proof of immunization or complete facility vaccination administration records. Records will be maintained in the individual's confidential health record and used only for determining compliance, outbreak control, and patient safety.

Exemptions and Accommodations

Exemptions for medical or sincerely held religious beliefs may be requested. Requests must include supporting documentation as stipulated by facility procedure and will be reviewed in accordance with applicable laws and reasonable accommodation obligations.

I request a medical exemption

I request a religious exemption

Procedure for Administration and Adverse Events

Vaccines administered by the facility will follow accepted clinical protocols. Any adverse event following immunization should be reported immediately to facility clinical staff. The facility will provide post-vaccination care as appropriate and will document any adverse reaction in the medical record.

Declination of Vaccination

Individuals may decline one or more required vaccinations. Declination may result in restrictions on duties, placement, or access to certain patient care areas in accordance with facility policy. Indicate below if you decline and provide a reason.

I decline one or more required vaccinations

Privacy; Use of Records

Vaccination records are protected health information. The facility will use and disclose records only as permitted by law for clinical care, public health reporting, quality assurance, and compliance with legal obligations. By signing below you acknowledge receipt of this privacy policy as it relates to immunization records.

Acknowledgment of Privacy Notice:

Consent and Certification

I certify that the information I have provided in this form is true and complete to the best of my knowledge. I have read and understand the facility's Vaccination Policy. By checking the box below I authorize the facility and its authorized healthcare providers to administer the indicated vaccines and to record such administration in my health record. I understand that I may withdraw consent in writing, except where withdrawal is limited by law or public health requirements.

I consent to vaccination and to the recording of immunization data in my medical record

Authorization Expiration Date:

Certification

By signing below I acknowledge that I have had the opportunity to ask questions about the risks and benefits of the vaccines and that my questions have been answered to my satisfaction. I understand the facility's right to verify vaccination status and to take measures necessary to protect patients and staff in the event of exposure or an outbreak.

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