Fillable Acknowledgment and Statement of Declination of the COVID-19 (California Institute of Technology)

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Acknowledgment and Statement of Declination of the COVID-19 (California Institute of Technology)

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{00083694-8}
Acknowledgment and Statement of Declination of the COVID-19 Vaccine
COVID-19 is a highly transmissible respiratory illness that the World Health Organization has declared a
pandemic. It causes symptoms ranging from mild to severe and can lead to life-threatening illness,
hospitalization, and death. COVID-19 vaccines have been carefully evaluated in clinical trials and authorized
by the Food and Drug Administration (FDA) for emergency use. These vaccines make it substantially less
likely an individual will contract COVID-19 and become seriously ill or die, and they protect not only the
individuals vaccinated, but also others in the community.
I
n order to maximize the health and safety of the entire Caltech community, the Institute will require all
students to receive the COVID-19 vaccine once it is fully licensed (approved) by the FDA, subject to limited
exemptions. In the meantime, and during the period that several COVID-19 vaccines are granted
emergency use authorization (EUA) status, the Institute will require that all students either submit proof of
receiving the COVID-19 vaccine or execute this Acknowledgment and Statement of Declination of the
COVID-19 Vaccine.
B
y signing below, I acknowledge the following:
• I have access to information about COVID-19 vaccines
.
• I have opportunities to receive the COVID-19 vaccine, at no charge to me.
• If
I decline the COVID-19 vaccine, I recognize and accept that there will be consequences including
but not limited to:
o I may be at risk of contracting COVID-19 and spreading it to others.
o I will be required to isolate or quarantine if I contract COVID-19 or am exposed to a
confirmed case.
o I will be required to participate in COVID-19 testing at a frequency to be determined by the
Institute, which may be more frequently than vaccinated individuals.
o I may be required to take additional measures, such as wearing additional personal
protective equipment, maintaining social distancing, participating remotely, and/or other
risk mitigations.
o I may not be eligible to live in or access student housing or student activities.
o I may not be able to attend Institute-sponsored or on-campus events.
o I may not be eligible to participate in certain extracurricular activities, such as athletics
,
p
erforming arts, etc.
• Caltech may change its vaccination policy
in the future and require additional measures to ensure
the health and safety of myself and others.
• I understand Caltech will require all students to receive COVID-19 vaccines once they are fully
a
pproved by the FDA, subject to limited exemptions allowed by law.
After considering the above, I choose not to receive the COVID-19 vaccine at this time. It is my
responsibility to be cognizant of Institute policies and restrictions, and I agree that I will comply with all
existing and future policies and procedures regarding COVID-19 to protect the health and safety of myself
and others.
B
y signing below, I verify that I am declining COVID-19 vaccination at this time.
S
ignature: __________________________________ Date: ________________________
Print Name: _________________________________ Caltech ID: ____________________
Email: ______________________________________ Telephone: ____________________
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Acknowledgment and Statement of Declination of the COVID-19 (California Institute of Technology)

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Completed 5 October 2021

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