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Request for Accommodation: Religious Exemption from Vaccination

To  request an exemption from required vaccinations, please complete the form below and return this form to the human resources department.

​Name (print):
Manager:​​Work/Cell Phone:

I am requesting a religious exemption from [Company Name]'s mandatory vaccination policy for the following vaccination(s):                                                                                                                 

Please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflicts with the vaccination requirement:




Please provide any additional information that you think may be helpful in reviewing your request. For example: 

  • How long you have held the religious belief underlying your objection.
  • Whether your religious objection is to the use of all vaccines, a specific type of vaccine or some other subset of vaccines.
  • Whether you have received vaccines as an adult against any other diseases.




I verify that the information I am submitting to substantiate my request for exemption from [Company Name]'s vaccination policy is true and accurate to the best of my knowledge. I understand that any falsified information can lead to disciplinary action, up to and including termination.

I further understand that [Company Name] is not required to provide this exemption accommodation if doing so would pose a direct threat to myself or others in the workplace or would create an undue hardship for [Company Name].

Employee Signature:



Date initial received: __/__/____      Date any additional documentation received: __/ __/ ___

Accommodation request:

  • Approved __/__/____   

Describe specific accommodation details:


  • Denied    __/__/____                    

Describe why accommodation is denied:



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