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 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.
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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