Nursing Home Staff
Vaccination Record Form

This form is to be completed by all staff members to document their vaccination status as part of our health and safety protocols. Please fill out the form accurately and return it to the designated health office within our facility.

Staff Member Information

Name		Position
Department		Submission Date

Vaccination Details

Please provide the following details for each vaccination received. Include all vaccinations required by our health protocols as well as any additional relevant vaccinations.

Vaccine Type	Brand	Date Received	Dose	Administered By

Medical Exemptions

If you have any medical exemptions for specific vaccines, please provide a detailed explanation and attach supporting documentation from a healthcare provider.

Vaccine Type	Reason for Exemption

Consent and Declaration

I hereby certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand the importance of vaccinations in preventing disease transmission within our facility and commit to maintaining up-to-date vaccination records as required.

Signatures

Staff Member

[Name]

[Date]

Reviewer

[Name]

[Date]

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