Request For Religious Exemption From Influenza Vaccination printable pdf download

Request For Religious Exemption From Influenza Vaccination

Religious Exemption Form

EQUEST FOR

ELIGIOUS

XEMPTION FROM

NFLUENZA

ACCINATION

Please print the following information:

Name: _________________________ Date of request: __________________

Email address: ___________________ Phone No.: ______________________

Department/School/Company: __________________

Position/title: __________________ Supervisor/Manager: _______________________

Washington University requires healthcare personnel who provide patient care services or work in

patient care or clinical care areas to receive an annual influenza vaccination. Leading healthcare

authorities and organizations recommend influenza vaccination for healthcare workers because it

has been shown to be effective in minimizing the incidence and adverse effects of the illness on

patients and workers ( ).

To apply for an exemption from the required influenza vaccination based on a sincerely held

religious belief, practice or observance, please (1) identify the religious belief practice or

observance, and (2) explain why it precludes you from receiving the influenza vaccination.

_________________________________________________________________

In some cases, Washington University will need to obtain documentation or other authority

regarding your identified religious belief, practice or observance. The University may need to

discuss the nature of the religious belief, practice or observance with a spiritual leader or scholar

of your religion (if applicable) to address your request for an exemption. If requested, can you

obtain documentation or other authority to support the need for a religious exemption?

Yes _______

No ______

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Request For Religious Exemption From Influenza Vaccination