Done COVID Religious Form.pdf
Part I: To be completed by the Individual Requesting an Exemption/Accommodati on
“1. identify your sincerely held religious belief, practice, or observance that you believe”
specifically conflicts with the Company’s COVID-19 vaccination requirement:
“2. explain how your sincerely held religious belief, practice, or observance specifically” “conflicts with the Company’s COVID-19 vaccination requirement, and identify and describe the accommodation that you are requesting to eliminate the conflict, as well as any alternative accommodations that you believe will eliminate the conflict:”
“3. When did you begin following or subscribing to this religious belief, practice, or observance?”
“4. Would the religious belief, practice,or observance allow you to take the influenza, rubella (MMR),”
“and/or hepatitis A vaccine, if it was required in order to work? And if so, why does the religious belief, practice, or observance allow you to take those vaccines but not the COV ID-19 vaccine?”
“5. identify any sources (e.g., religious texts), if any, that describe how your particular”
“sincerely held religious belief,practice, or observance specifically conflicts with the Company’s COVID-19 vaccination requirement (or state “”None,”” if applicable):”
2
NOTE: Individuals are welcome to use additional sheets to explain the basis for their request.
“If your request is approved, you will be exempted or receive a deferral from receiving the COVID- 19”
“vaccine. If your request is not approved, you will be expected to receive the COVID-19 vaccine and comply with the Mandatory COVID- 19 Vaccination Policy .”
My signature below affirms that I have read and understand the information on this form and that my
“request for a religious accommodation for the COVID- 19 vaccination is based upon sincerely held religious beliefs, observances and practices.”
