Vaccine Declination Form

Rowan University

COVID-19 Vaccine Declination Form

SAMPLE FORM: To enter your information, visit

go.rowan.edu/wellnessforms

Rowan University requires all students to be vaccinated against a variety of

communicable diseases, including COVID-19. Students may opt out of the COVID-19

vaccine while it is authorized on an emergency use basis due to medical, religious or

personal reasons.

The reason I am opting out is:

⃞ Medical

⃞ Religious

⃞ Personal (only applies while the COVID-19 vaccine is authorized on an emergency

use basis)

DECLINATION: I decline the COVID-19 vaccine. Please read and accept the following.

Each box must have an initial for this form to be considered complete.

⃞ I understand COVID-19 is a respiratory illness caused by a coronavirus that may

cause mild to moderate illness, like the common cold, but can also lead to dangerous

complications. Some individuals are more likely to develop serious illness including

hospitalization, intensive care unit admission and death.

⃞ I understand the COVID-19 vaccine has been carefully evaluated in clinical trials

and has been authorized for emergency use because it makes it substantially less likely

that an individual will contract COVID-19 and become seriously ill. Getting vaccinated

protects you and may also protect others, particularly those who are at increased risk

for severe illness from COVID-19.

⃞ I acknowledge that I have received information from Rowan about the COVID-19

vaccine. I understand that I may be at risk of acquiring COVID-19 infection and

spreading it to others. I decline the COVID-19 vaccine at this time. I understand that by

declining this vaccine, I continue to be at risk of acquiring COVID-19, a serious disease.

If, in the future, I am vaccinated with the COVID-19 vaccine, I will provide proof of

vaccination (i.e., documents that provide dates of vaccinations).

⃞ I understand Rowan will require me to submit to regular surveillance testing and

may require me to wear additional personal protective equipment while I am on campus.

I also understand I will be subject to quarantine and isolation procedures if I test positive

or come in close contact with someone who has tested positive.

⃞ I understand that Rowan may change its vaccination policy in the future and

require additional measures for those who are unvaccinated.

⃞ I understand and agree to the terms, conditions and guidelines described above.

I further understand that by typing my name below, I have completed the declination

form electronically and agree that my typed name is the equivalent of my manual

signature.

NEXT STEP

MEDICAL EXEMPTION: If you chose the medical exemption, submit a signed

statement of medical exemption from your primary care provider to

go.rowan.edu/wellnessupload

RELIGIOUS EXEMPTION: If you chose the religious exemption, submit a statement

explaining that immunizations conflict with your religious beliefs to

go.rowan.edu/wellnessupload

PERSONAL EXEMPTION: If you chose the personal exemption, your exemption only

applies while the vaccines are authorized on an emergency use basis. No further

documentation is required.