{"content":[{"text":"Form for Employees Whose Employers \n Are Requiring Covid-19 Injectons","bbox":{"left":0.09281,"top":0.071668,"width":0.470381,"height":0.055521}},{"text":"NOTE TO EMPLOYEE: Be sure to document the date and tme you submit this form to your employer; \n also document the date and tme and their response if they refuse to sign it.","bbox":{"left":0.09281,"top":0.164235,"width":0.7936989999999999,"height":0.03692999999999999}},{"text":"NOTE TO EMPLOYER: As your employee, I am requestng that you review this document, provide the \n requisite informaton, and sign the form, in regards to your requirement that employees get a Covid- \n 19 emergency use authorizaton (EUA) investgatonal vaccine.","bbox":{"left":0.09281,"top":0.219664,"width":0.8007679999999999,"height":0.05549100000000004}},{"text":"1) If I agree to receive an EUA Covid-19 injecton, does my employee health insurance plan provide \n complete coverage should I experience an adverse event, or even death?","bbox":{"left":0.09281,"top":0.293654,"width":0.7891219999999999,"height":0.03705700000000001}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.34921,"width":0.8093349999999999,"height":0.018496000000000012}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.386205,"width":0.8093349999999999,"height":0.018496000000000012}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.4232,"width":0.8093349999999999,"height":0.018496000000000012}},{"text":"2) As an employee, does my life insurance policy provide any coverage in the event that I die from \n receiving an EUA Covid-19 injecton?","bbox":{"left":0.09281,"top":0.478629,"width":0.783147,"height":0.03705699999999995}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.534185,"width":0.8093349999999999,"height":0.018495999999999957}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.57118,"width":0.8093349999999999,"height":0.018495999999999957}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.608175,"width":0.8093349999999999,"height":0.018495999999999957}},{"text":"3) As an employee, will you be providing Workers’ Compensaton, disability insurance, or other \n resources if I have an adverse event to an EUA Covid-19 injecton and am unable to come to work for \n days, weeks, or months, or if I am disabled for life?","bbox":{"left":0.09281,"top":0.663604,"width":0.803471,"height":0.05549099999999996}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.737594,"width":0.8093349999999999,"height":0.018495999999999957}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.774589,"width":0.8093349999999999,"height":0.018495999999999957}},{"text":"___________________________________________________________________________________","bbox":{"left":0.09281,"top":0.811584,"width":0.8093349999999999,"height":0.018495999999999957}},{"text":"4) The Food and Drug Administraton (FDA) requires that EUA vaccine recipients be provided with \n certain vaccine-specifc informaton to help them make an informed decision about vaccinaton.8 \n The EUA fact sheets that must be provided are specifc to each authorized Covid-19 injecton and are","bbox":{"left":0.09281,"top":0.867139,"width":0.8005800000000001,"height":0.05549099999999996}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}