To request an exemption from required vaccinations, please complete the form below and return this form to the human resources department.
Name (print): | Date: |
Dept.: | Position: |
Manager: | Work/Cell Phone: |
I am requesting a religious exemption from [Company Name]'s mandatory vaccination policy for the following vaccination(s):
Please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflicts with the vaccination requirement:
_______________________________________________________________________
_______________________________________________________________________
Please provide any additional information that you think may be helpful in reviewing your request. For example:
- How long you have held the religious belief underlying your objection.
- Whether your religious objection is to the use of all vaccines, a specific type of vaccine or some other subset of vaccines.
- Whether you have received vaccines as an adult against any other diseases.
_______________________________________________________________________
_______________________________________________________________________
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: |
HR USE ONLY
Date initial received: __/__/____ Date any additional documentation received: __/ __/ ___
Accommodation request:
- Approved __/__/____
Describe specific accommodation details:
______________________________________________________________________
- Denied __/__/____
Describe why accommodation is denied:
______________________________________________________________________
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