Affidavit of Employee Consent for COVID-19 Vaccination – Soft Copy Editable Template

Section 21 of Republic Act No. 3720, as amended, provides that any new drug should have an authorization from the FDA based on an application containing full reports of investigations to show whether or not such drug is safe, efficacious and of good quality for use based on clinical studies, prior to manufacture, sale, importation, exportation, distribution or transfer thereof.

Pursuant to Proclamation Nos. 922 (s. 2020) and 1021 (s.2020), the Philippines was declared under a State of Public Health Emergency, and a State of Calamity due to the COVID-19 pandemic.

Subsequently, Republic Act No. 11494 or the “Bayanihan to Recover as One Act” was enacted authorizing the President to suppress the COVID-19 pandemic through the procurement of drugs and vaccines.

The President of the Republic of the Philippines issued Executive Order (EO) No. 121 entitled “Granting Authority to the Director General of the Food and Drug Administration to Issue Emergency Use Authorization (EUA) for COVID-19 Drugs and Vaccines, Prescribing Conditions therefore and for other Purposes.” Said issuance gave authority to the Director General to issue an EUA, and established the conditions under which said authorization may be issued.

The FDA introduced the process for the issuance of EUA to sustain and strengthen the national preparedness for the COVID-19 public health emergency. The principles of regulatory reliance and recognition are adopted to accelerate the evaluation and approval process for EUA to ensure immediate access to drug products and vaccines for COVID-19.

Since there are no laws, rules, or regulations requiring employees to undergo vaccination, the employer does not have clear legal basis to prosecute employees who may refuse to get the jab.

At any rate, the employer can obtain the consent of the employee where the latter executes a document consenting to the vaccine, accepting its risks and benefits, as well as waiver of the Data Privacy Law.

The template in this product is in Affidavit Format, written in Word 360 and is editable. Below are the contents of the Affidavit containing declarations, acknowledgment and undertaking of the employee in giving consent to the vaccination:

1. Last Name, First Name, Middle Initial
2. Date of Birth
3. Gender
4. Address
5. Phone Number
6. Email
7. Name of Provider
8. Statement of legal age
9. Statement of consent
10. Clause stating understanding that the vaccination is voluntary and that the employee is not required to receive this vaccine or to receive this vaccine as a condition of employment
11. Acknowledge that it is not possible to predict all possible side effects or complications associated with receiving the vaccine.
12. Understanding that the employer is not making any representations or warranties regarding the vaccine and its general safety
13. The employee has been provided with and has read the Emergency Use Authorization (“EUA”)
14. Statement that the employee was given the opportunity to ask questions about the vaccine, including but not limited to the risks and benefits of the vaccine, and all of questions have been answered to satisfaction.
15. Statement that the employee read and understood the benefits and risks of vaccination, and he voluntarily assumes full responsibility for any reactions that may result from receiving the vaccine
16. Understanding that the employee may be asked to remain in the vaccination administration area for 15 to 30 minutes after the vaccine is administered to be monitored for potential adverse reactions, and agree to report any complaints that I may have to the provider while there.
17. After leaving the facility, understanding that if the employee experiences any side effects, he should either call his physician or go to the nearest emergency department
18. Statement of understanding that in order for the vaccine to be effective, he must receive two doses
19. Statement that the employee has been provided an appointment date to receive the second dose, and understand that it is solely his responsibility to return for this second dose at the scheduled time
20. Acknowledgment that employee’s failure to appear for the scheduled appointment will compromise the effectiveness of the vaccination
21. Authorization to the employee to use and disclose any and all information related to my priority to receive, and actual receipt of the COVID-19 vaccine, including outreach for scheduling, the date of appointments, whether the employee appears for the appointments and any information he discloses or reports to the employer relating to the experience with the vaccine, including side effects or the development of COVID-19 symptoms within the employer, including, without limitation, Human Resources, and Occupational Health and Safety Committee

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