COVID Religious Form.pdf
Part I: To be completed by the Individual Requesting an Exemption/Accommodation
Name: Phone Number: Position/Job Title: Coordinator/Supervisor: E-mail Address:
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 COVID-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):
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