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Request for Accommodation: Medical Exemption from Vaccination

To request an exemption from required vaccinations, please complete Section 1 below and have your medical provider complete Section 2 before returning this form to the human resources department.

Section 1

​Name (print):
​Work/Cell Phone:

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


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:




Section 2

Medical Certification for Vaccination Exemption

Employee Name: _________________________________________________

Dear Medical Provider,

[Company Name] requires vaccination against [insert disease name, such as COVID-19, influenza, etc.) as a condition of employment. The individual named above is seeking an exemption to this policy due to medical contraindications.

Please complete this form to assist [Company Name] in the reasonable accommodation process.


The person named above should not receive the [insert disease name] vaccine due to:





This exemption should be:

  •  Temporary, expiring on: __/__/____, or when ______________________________.
  •  Permanent.


I certify the above information to be true and accurate, and request exemption from the [insert disease name] vaccination for the above-named individual.

Medical Provider Name (print):

Medical Provide Signature: 


Practice Name & Address: 

Provider Phone:




Date of initial request: __/__/____                          Date certification received: __/__/____

Accommodation request:

  •  Approved  __/__/____   

  Describe specific accommodation details: _________________________________________________________________


  •  Denied  __/__/____                    

  Describe why accommodation is denied: _________________________________________________________________              




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