Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

City of Newport News COVID-19 Vaccine Declination Form 2020

  1. My employer, in partnership with the Virginia Department of Health, recommends that I receive the COVID-19 vaccination to protect myself, family, co-workers, and others.

  2. I acknowledge that I am aware of the following facts (please read and check each box):

  3. COVID-19 is a serious contagious virus that can easily spread from person to person. Some infected persons may have severe disease and die. No one knows how COVID-19 may affect them.*

  4. The COVID-19 vaccination is recommended for me and for all others to help prevent spreading the disease to friends, family and staff and to protect me from getting COVID-19, or from serious illness if I do get infected.*

  5. I understand that, if I get COVID-19 then, I will be required to isolate away from others and will not be able to work for a minimum of 10 days after symptoms appear or 10 days from the date I test positive, if I have no symptoms.*

  6. I understand that, if I become infected with COVID-19 then, even if my symptoms are mild or non-existent, I can spread the virus to others. Symptoms that are mild or non-existent in me can still cause serious illness and death in others.*

  7. I understand that I cannot get COVID-19 from the vaccine and getting the vaccine is a safer way to build up immunity.*

  8. I understand that side effects usually go away on their own within a week and are a sign that the immune system is working.*

  9. The consequences of declining to be vaccinated could be life threatening for me and the health of everyone with whom I have contact, including my co-workers and family.*

  10. Despite all of these facts, I choose to decline the COVID-19 vaccination.

  11. I understand that I can change my mind at any time and accept the COVID-19 vaccination.*

  12. I have read and fully understand the information on this declination form.*

  13. Leave This Blank:

  14. This field is not part of the form submission.