To request an exemption from required vaccinations, please complete Section 1 below and have your medical provider complete Section 2 before returning this form to the human resources department.
Section 1
| Name (print): | Date: |
| Dept.: | Position: |
| Manager: | Work/Cell Phone: |
I am requesting a medical exemption from [Company Name]'s mandatory vaccination policy for the following vaccination(s):
I verify that the information I am submitting to substantiate my request for exemption from [Company Name]'s vaccination policy is true and accurate to the best of my knowledge. I understand that any falsified information can lead to disciplinary action, up to and including termination. I authorize the information from my medical provider as noted on the Medical Certification for Vaccination Exemption form to be shared with [Company name].
I further understand that [Company Name] is not required to provide this exemption accommodation if doing so would pose a direct threat to myself or others in the workplace or would create an undue hardship for [Company Name].
| Employee Signature: | Date: |
Section 2
Medical Certification for Vaccination Exemption
Employee Name: ____________________________________________________________
Dear Medical Provider,
[Company Name] requires vaccination against [insert disease name, such as COVID-19, influenza, etc.) as a condition of employment. The individual named above is seeking an exemption to this policy due to medical contraindications.
Please complete this form to assist [Company Name] in the reasonable accommodation process. Sufficient medical documentation should describe the nature, severity, and duration of the impairment, the activity or activities that the impairment limits, the extent to which the impairment limits the employee's ability to perform the activity or activities, and should also substantiate why the requested reasonable accommodation is needed.
The person named above should not receive the [insert disease name] vaccine due to:
|
This exemption should be:
|
I certify the above information to be true and accurate, and request exemption from the [insert disease name] vaccination for the above-named individual.
Medical Provider Name (print): | |
Medical Provide Signature: | Date: |
Practice Name & Address: | Provider Phone: |
HR USE ONLY
Date of initial request: __/__/____ Date certification received: __/__/____
Accommodation request:
- Approved __/__/____
Describe specific accommodation details:
- Denied __/__/____
Describe why accommodation is denied:
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