Religious Exemption Request - Seasonal Influenza Vaccine printable pdf download

Religious Exemption Request - Seasonal Influenza Vaccine

Religious Exemption Request – Seasonal Influenza Vaccine

This section to be completed by the individual requesting a religious exemption

Name

Contact Phone Number:.

Date of Birth:

Home Address:

Leader Name:.

I am a(n):

employee

student

contractor

vendor

volunteer

Crothall

Morrison

Employee ID number or Worker ID#:

☐ Full‐time ☐ Part‐time ☐ PRN

Department #

I request a religious exemption from the seasonal influenza vaccination. I understand that this form must be completed and

returned to Flu exemption mailbox by the deadline of _______________. I also understand that if I am granted an exemption, I

must wear a surgical mask at all times when I am in direct contact with, or within 6 feet of, any patient for the duration of the flu

season. If I am not granted an exemption, I must receive the vaccination as required by policy.

Individual’s Signature

Date

This section to be completed by employee

Influenza vaccination is the most effective method of controlling the spread of influenza, and the Advisory Committee on

Immunization Practices (ACIP) strongly recommends that all health care workers receive the vaccine. In keeping with our

commitment to patient safety and First Do No Harm, Novant Health now requires its employees, physicians, allied health

professionals, students, contractors, vendors and volunteers to receive a seasonal influenza vaccination.

The individual named above has requested a religious exemption. Please complete the bottom portion of this form so that we

may consider this request. Failure to provide information below may result in exemption denial.

Sincerely yours,

Tom Zweng, MD

Executive Vice President & Chief Medical Officer

Novant Health

Explanation of Religious Belief

Name of Religion

Please explain the religious belief and how it relates to the influenza vaccine (note – dietary restrictions based on pork no longer

support a religious exemption, as the vaccine is now available without pork components)

Religious Leader Signature

(Signature Optional)

Send completed form to Flu Exemption mailbox

Version: 2014.11.15

Religious Exemption Request - Seasonal Influenza Vaccine