DATE (MM/DD/YYYY):
COVID-19 VACCINATION
I am a VHA:
CHECK ONE STATEMENT BELOW AND COMPLETE AND SIGN THE LAST SECTION OF THIS FORM PRIOR TO
SUBMISSION TO EMPLOYEE OCCUPATIONAL HEALTH:
I have a contraindication for the COVID-19 vaccine as defined by Centers for Disease Control and Prevention (CDC). The
reasons for contraindication must be recognized contraindications and precautions by the CDC, found here:
https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html?CDC_AA_refVal=https%3A%2F%
2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-product%2Fclinical-considerations.html, located under Interim Clinical
Considerations for Use or Vaccine Indications. This has been discussed and acknowledged by my personal physician. I
understand that by declining to receive the vaccine within eight weeks of publication of this directive, or within eight weeks of
beginning employment, I must wear a face mask according to requirements and guidelines within VHA Directive 1193,
COVID-19 Vaccination Program for VHA Employees and Health Care Personnel.
Printed Physician Name and Address
Physician Signature
Date (MM/DD/YYYY)
Supervisor Email
Supervisor Signature
Date (MM/DD/YYYY)
Date (MM/DD/YYYY)
National Provider Identification Number
Supervisor Signature
Supervisor Email
I understand that by declining to receive the vaccine within eight weeks of publication of this directive, or within eight weeks
of beginning employment, I must wear a face mask according to requirements and guidelines within VHA Directive 1193,
COVID-19 Vaccination Program for VHA Employees and Health Care Personnel.
Employee Other - please indicate:
I received the full COVID-19 vaccine series (any required documentation is attached).
I have been granted a medical exemption from receiving the COVID-19 vaccine.
I notified my immediate supervisor in writing that I have a deeply held religious belief that prevents me from receiving the
COVID-19 vaccine.
I have read and fully understand the information on this form and have been given the opportunity to have my questions
answered. I understand that violation of the directive may result in disciplinary action up to and including removal from Federal
service.
Name (print): Last 4 SS#:
Dept./Serv:
Employee Signature:
Date (MM/DD/YYYY):
VHA Title 38HCP are to provide this form to the VHA facility Employee Occupational Health Office. Secure electronic
submission is permissible.
VA FORM
JUL 2021
10-263
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