COVID-19 vaccination medical exemption

To request a medical exemption from the COVID-19 vaccination:
1. Please fill out this form.
2. Download the medical provider form and have your medical provider complete it. Return that document to the Human Resources Department.
These forms must be completed in full for the accommodation request to be processed. Forms completed solely by the employee will not be accepted.
First name*
Last name*
Department/Project*
Position*
Supervisor
Work/cell phone number*
DOWNLOAD THIS PDF DOCUMENT: Part 2 medical provider form
I am requesting a medical exemption from receipt of the COVID-19 vaccine and any applicable Company policy or applicable laws with respect to receipt of the vaccine. I verify that the information I am submitting to substantiate my request for exemption from receipt of the COVID-19 vaccine 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 of employment. I further understand the Company 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 the Company and that the Company may need to revise an accommodation based on changed circumstances.*
- I authorize this response to be my digital signature.
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