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Employee ID:
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To request a religious exemption from receiving the COVID-19 vaccine, you must complete and submit the form below.
By checking the below boxes and submitting this form, you certify the following statements are true and correct.
If you cannot truthfully agree to each of the below statements, you may not submit a request for religious exemption.
I hereby certify that receiving the COVID-19 vaccine would violate my sincerely held religious beliefs, practices, or observances (or, if I work in Texas, my personal conscience; or, if I work in Utah, my sincerely held personal belief; or, if I work in Illinois, my conscience or conscientious conviction), and that this is the reason for my exemption request. I understand that I am required to receive a COVID-19 vaccination unless I am granted an exemption.
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 that my request will be reviewed and an accommodation will be considered but is not guaranteed.
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 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 as apply to my job role.
In the space provided below: (1) describe in detail the nature of your sincerely held religious beliefs, practices, or observances (or, if you work in Texas and are requesting an exemption based on reasons of personal conscience, the nature of your reasons of personal conscience; or, if you work in Utah and are requesting an exemption based on a sincerely held personal belief, the nature of your personal belief; or, if you work in Illinois and are requesting an exemption based on your conscience or conscientious convictions, the nature of your conscientious conviction); and (2) explain why those beliefs prevent you from receiving the COVID-19 vaccine. Failure to provide this information may result in the denial of your religious exemption request. Please do NOT copy / paste graphic images or other text or try to attach any documents. Please type only text in the field below.
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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.