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Flu Religious Exemption

The employee is requesting a religious exemption from the flu vaccine requirement. They explain that their bona fide religious belief prevents them from receiving the flu vaccine. They acknowledge the potential risks of not being vaccinated but assert that approval of the exemption would not mean they could work without accommodations such as continuous masking. The employee certifies that the information provided is accurate and understands that false claims could result in termination.

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FRANCHESCA DEL MUNDO
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919 views3 pages

Flu Religious Exemption

The employee is requesting a religious exemption from the flu vaccine requirement. They explain that their bona fide religious belief prevents them from receiving the flu vaccine. They acknowledge the potential risks of not being vaccinated but assert that approval of the exemption would not mean they could work without accommodations such as continuous masking. The employee certifies that the information provided is accurate and understands that false claims could result in termination.

Uploaded by

FRANCHESCA DEL MUNDO
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Employee Request for Religious Exemption: Flu Vaccine

2022-2023

I request to be exempted from the vaccine requirement on the basis of my bona fide
religious belief, observance or practice. The following information is submitted in
support of my request for exemption.

(Please attach additional pages, if needed)

1. Please explain the religious belief, observance, or practice that prevents you
from receiving the flu vaccine.

2. Please describe the specific conflict between your religious belief, observance or
practice and the flu vaccine. In your response, please address the following:
a. What are the specific reasons the vaccine requirement conflicts with your
religious beliefs, observances or practices?
3. Please provide any information that will help us to determine that your belief is
sincerely held with the strength of transitional religious views. For example, does
this belief affect any other aspect of your life? Please provide any details you feel
are relevant.

4. Please identify any job accommodations(s) that would resolve the conflict
between your religious belief, observance or practice and the vaccine
requirement. Be as specific as possible.
By signing below, I certify that the information I have provided in this request for
exemption is true and accurate. I understand that submitting false information on this
request for exemption will subject me to corrective action, up to and including
termination of employment. I confirm that my religious beliefs, for which I seek this
exemption, are sincerely held. I understand:
● Due to my occupational exposure I may be at risk of acquiring the Flu. I have
been given the option to schedule my own Flu vaccine, at no charge to me;
however, I decline the Flu vaccine at this time.
● By declining this vaccine I continue to be at risk of acquiring the Flu, a serious
and potentially life threatening infection.
● I continue to have occupational exposure to potentially infectious materials and if
I want to be vaccinated with the Flu vaccine, I can receive the vaccination at no
charge to me.
● Approval of this exemption does not mean that I am cleared to work without any
further accommodations;
● Accommodations may include continuous masking or other measures as the Flu
and business circumstances warrant.
● This declination is solely for the purpose of Trusted Health. Each healthcare
facility may have their own declination forms and may or may not accept
declinations at this time.

Signature:

Print:

Date:

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