Notice of Noncompliance with Mandatory Vaccination Policy

Date:

To:

From:

RE: Noncompliance with mandatory vaccination policy

[Company Name] implemented a policy effective [date] requiring all employees to be fully vaccinated against COVID-19 no later than [date]. As of today, you have not provided evidence of your COVID-19 vaccination status and are not in compliance with [Company Name]'s COVID-19 safety policy.

Please choose one of the following options and return this signed form to human resources before [date] :

[Insert a description of available options. The following are examples.

• Provide valid documentation to human resources that you are fully vaccinated against COVID-19 no later than [date].
• Submit a request for accommodation for an exception to the vaccination requirement due to a substantiated medical or religious reason no later than [date].
• Request an unpaid leave of absence of no more than 30 days in order to obtain all required doses of a COVID-19 vaccine.
• Submit a notice of voluntary resignation effective immediately.]

________________________    ________________________               ________________
Employee name                             Employee signature                                  Date

If you would like to discuss the above options with human resources prior to making a decision, please contact [name and contact information] no later than [date].     

Failure to comply with one of the options above, or to return this form to human resources by [date], will result in disciplinary action, up to and including termination of employment.