Flu Waiver-Religious

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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:

  1. Please explain your religious reason for not receiving the flu vaccine: ______________________________________________________________________

  2. 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: ___________________________________

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.