COVID-19 vaccination religious exemption

To request an exemption from the COVID-19 vaccination due to a sincerely held religious belief, please fill out this form. This information will be used by Human Resources or other appropriate personnel to engage in an interactive process to determine eligibly for and to identify possible accommodations. If an employee refuses to provide such information or engage in the interactive process, the employee’s refusal may impact the Company’s ability to adequately understand the employee’s request or effectively engage in the interactive process to identify possible accommodations.
If you are a member of a union, please consult with your Human Resources Department or union steward to inquire if there is a union specific form to complete.
First name*
Last name*
Department/Project*
Position*
Supervisor
Work/cell phone number*
Describe the sincere and meaningful religious belief or practice that necessitates this request for accommodation, including the nature and scope of your opposition to the COVID-19 vaccine (please note a religious belief or practice is not something that is based on groups of political, social, or personal philosophy, preference or convenience under applicable law):
Please explain the accommodation requested.
Describe any alternate accommodations that might address your needs.
In some cases, the Company may need to obtain additional information about your religious practice(s) or belief(s). If requested, can you provide additional information to support your sincerely held religious belief(s) and need for an accommodation?
- Yes
- No
If no, please explain why.
I verify that the information I am submitting in support of my request for a religious accommodation is complete and accurate to the best of my knowledge, and I understand that any intentional misrepresentation contained in this request may result in disciplinary action up to and including termination. I affirm and attest that my objections to the COVID-19 vaccine are due to my sincerely held religious beliefs and are NOT based on grounds of political, social, or personal philosophy, preference, or convenience, and that all information provided herein is true and accurate. I further understand the Company 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 to the Company and that the Company may need to revise an accommodation based on changed circumstances.*
- I authorize this response to be my digital signature.
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