Religious Exemption Request Form for Influenza Vaccine
You will be notified by letter if your exemption was approved or denied. If this is not the best method, please provide us with the information we need to contact you.
Legal Name: ___________________________________
Date of Birth or Employee ID#: ______________________
Work number: _______________________
Personal phone: _______________________
Home address: _______________________
Email: ___________________________________
Facility: __________________________________________
Employee unit/department: ___________________________________
Shift: __Days __Nights
Please answer the following questions to help us understand the reasons for requesting a Religious Exemption to the flu vaccine:
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Please explain your religious reason for not receiving the flu vaccine: ______________________________________________________________________
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Please complete the following:
a. My relationship to this religion is: ___________________________________
b. When was the last time you received the flu vaccine? ___________________________________
c. If you have received the flu vaccine before, what has changed since then? ______________________________________________________________________
Employee Signature: ___________________________________
Date:_________________
Employee Name:___________________________________
Internal Use Only:
[ ] Exemption approved [ ] Exemption Denied [ ] Further clarification needed
If approved:
[ ] Permanent Exemption
Clarification needed:______________________________________________________________________
Flu Exemption Committee Representative Signature:___________________________________
Date notification sent to employee: ________________
Submit to the Employee Health Department or Fax to Employee Health at 812-238-7287.
Thank you.
