HR Vaccination Consent Form

HR Vaccination Consent Form

Personal Information

Position Information

Vaccination Status and Request

Please indicate your current vaccination status and your request regarding employer-provided vaccination services.

I request to receive the employer-offered vaccination today at the occupational health location.

I have already received the vaccine. If checked, provide details below.

Medical Screening

Please indicate any of the following conditions that apply to you. Checking any box will prompt further review by occupational health.

Known allergy to vaccine components (e.g., polyethylene glycol).

Prior serious adverse reaction to a vaccine.

Currently pregnant or breastfeeding.

Consent, Authorization, and Acknowledgements

I, , hereby consent to the administration of the vaccine described above by authorized medical personnel retained by the employer. I acknowledge that:

1. The vaccine has been explained to me, including potential benefits and reasonably foreseeable risks and side effects, and I have had the opportunity to ask questions.
2. I authorize the release of vaccination and relevant medical records to my employer for purposes of verifying vaccination status, compliance with workplace health and safety policies, and recordkeeping. This authorization is limited to vaccination records and does not authorize unrelated health record disclosure.
3. If I experience an adverse reaction, I authorize emergency medical treatment deemed necessary by medical personnel on site and agree to promptly notify occupational health of any such event.
4. I understand that vaccination may be a condition of employment in certain positions; refusal may result in reassignment, testing, or other measures consistent with company policy and applicable law.

By checking the box below I provide the following authorizations and acknowledgements:

I hereby consent to vaccination and to the limited release of vaccination records to my employer as described above.

I decline vaccination at this time. I understand that by declining I may be subject to alternative safety requirements (for example, periodic testing, PPE, and/or restrictions on certain duties) consistent with employer policy and applicable law.

Privacy and Recordkeeping

Vaccination records will be maintained in a confidential personnel or medical file in accordance with applicable privacy laws and company policy. Only personnel with a business need-to-know will have access to these records. Your authorization above permits disclosure of vaccination status to third parties on a need-to-know basis for public health, workplace safety, or administrative purposes.

Legal Disclosures

At-Will Employment: Nothing in this form alters the at-will nature of employment unless expressly stated in a separate written agreement signed by an authorized company representative.

Equal Opportunity: The employer provides equal employment opportunity and does not discriminate on the basis of race, color, religion, sex, national origin, disability, age, or any other protected characteristic. Requests for reasonable accommodation related to vaccination should be made to Human Resources.

Employment History (for HR records)

Employer 1

Employer 2

Education

References

Please provide three professional references.

Applicant Certification & Authorization

I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I authorize the employer and its designated medical personnel to contact my prior healthcare providers as necessary to verify vaccination records or to obtain health information relevant to my ability to receive vaccination. I understand that falsification of information may subject me to disciplinary action up to and including termination.

I further authorize the release of vaccination records to the employer and/or its agents for purposes of confirming vaccination, workforce health surveillance, and any legally required reporting to public health authorities.

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