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Education Acknowledgement, Consent/Declination Form

Staff COVID-19 Vaccination

Date
Month
Day
Year

Education Acknowledgement, Consent/Declination Form

I have been offered the opportunity to obtain the Covid-19 vaccine
I have been provided education about the benefits, risks and potential side effects associated with the COCID-19 vaccine

I CONSENT TO BE VACCINATED OR I HAVE SHOWEN PROOF OF HAVING BEEN VACCINATED FOR COVID-19

DECLINATION: I have decided to decline the COVID-19 vaccination at this time

I understand that as a staff member of Sanilac Medical Care Facility, it is recommended that I get vaccinated against COVID-19 to maximize protection from COVID-19 infection in the facility and prevent inadvertent health outcomes for myself and/or others.

Personal Items

All resident’s personal items should go directly to the SMCF Laundry Department to be clearly labeled with their name upon admission.  Clothing will be marked in an inconspicuous place.  Unmarked items make it impossible to identify ownership and proper labeling will assure that your family member’s items remain safe with them.  Personal television sets are allowed and are properly set up by our Maintenance Department.

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