For reporting please use Google Chrome or Microsoft Edge browsers only.
Employee ID:
Name:
Work Email:
Date of Birth:
The State of Tennessee has passed legislation that places certain parameters on employer vaccination mandates. The applicable legal requirements are fluid and subject to change, but you may currently complete the form below to object to receiving a COVID-19 vaccine. You will be notified if a change in circumstances means that your objection can no longer be honored.
By checking the below boxes and submitting this form, you certify the following statements are true and correct.
I hereby certify that I object to receiving the COVID-19 vaccine.
I understand and assume the risks of non-vaccination, including the health risks I pose to myself and others with whom I may have contact.
I understand that I could be exposed to COVID-19 at work and could bring the virus into work.
I understand it is the Company’s policy that I complete COVID-19 vaccine training. I attest that I will complete this required training.
I understand I may change my mind at any time and receive the COVID-19 vaccination.
I understand that I must comply with the Non-Pharmaceutical Interventions (e.g., universal surgical mask use or respirator, regular COVID-19 testing, etc.) for unvaccinated or not fully vaccinated individuals as a condition of employment. These required non-pharmaceutical interventions are defined by my local and state regulations as apply to my job role.
In the space provided below describe in detail the nature of your objection to receiving a COVID-19 vaccine. Please do NOT copy / paste graphic images or other text or try to attach any documents. Please type only text in the field below.
By checking this box, I attest that I have read and fully understand the information on this form. I certify and attest that the information I have provided on this form is truthful and accurate. I understand and acknowledge that providing false information on this form is a violation of the Company’s policies, and will subject me to disciplinary action, up to and including employment termination.
