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Employee ID:
Name:
Work Email:
Date of Birth:
Requesting a Medical Exemption or Deferral is a multi-step process. All steps below must be completed and reviewed to receive approval.
You will receive notification of an exemption approval or denial within two weeks of completing these steps.
Bookmark this page, you may need to come back to complete your submission.
Do not enter your medical exemption unless you have your
COVID-19 Medical Exemption Validation Form
completed in full by your licensed medical provider.
If you have your form completed, proceed with all steps and submit.
Be sure your provider includes NPI number when signing the COVID-19 Medical Exemption Form
Lastly, complete the required COVID-19 Vaccine Training.
Next Steps
1. I am requesting a:
Permanent Medical Exemption
due to severe allergic reaction (e.g., anaphylaxis) after a previous dose or to component contained in all available COVID-19 vaccines or other permanent medical condition.
Temporary Medical Deferral
due to a time-limited medical contraindication recognized by the CDC or by the vaccines’ manufacturers, such as acute COVID-19 infection, immune-compromising treatment, or recent monoclonal antibody or convalescent plasma treatment.
Expiration Date:
Upload your signed form here.
(Note: File cannot exceed 2MB.)
2.
I attest to the truth and accuracy of the information documented in my COVID-19 Medical Exemption Verification Form.
2.
I attest to the truth and accuracy of the information documented in my COVID-19 Medical Exemption Verification Form.
3.
I understand that while my request is pending,
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 job duties, and/or the Enterprise. If my request for exemption is approved, I understand I will be required to continue complying with the Non-Pharmaceutical Interventions required by my local and state regulations job duties, and/or the Enterprise.