Request for Exemption from Mandatory COVID-19 Vaccination & Reasonable Accommodation Form

Employee Information

Name *

First

Last

Department *

Job Title *

Supervisor *

Email *

Phone *

Exemption Request Type (Check One)

Checkbox Items *

Medical Condition or ADA Disability*
Pregnancy or Pregnancy-Related Medical Condition
Sincerely Held Religious Belief, Practice, or Observance*

Reason for Exemption Request *

Please provide a detailed explanation of the reason for your exemption request. Attach any required supporting documentation as outlined in the policy.

*Medical/ADA Disability Exemption Requests

(Only applicable for medical/disability-based requests). Physician or healthcare provider’s certification is required for Medical/ADA Disability Exemption Requests. Attach a signed statement from a licensed healthcare provider stating the medical reason the COVID-19 vaccine is contraindicated and whether the condition is temporary or permanent.

Supporting Documentation

Click or drag files to this area to upload. You can upload up to 5 files.

*Religious Exemption Requests

(Only applicable for religious-based requests). Please describe your sincerely held religious belief, practice, or observance that prevents you from receiving the COVID-19 vaccine.

Requested Accommodation

Please describe any reasonable accommodation you believe would enable you to perform your job without receiving the COVID-19 vaccine.

Acknowledgment and Signature *

By signing below, I certify that the information I have provided is true and correct to the best of my knowledge. I understand that providing false or misleading information may result in disciplinary action. I also acknowledge that approval of this request is not guaranteed and that Larkin University may require additional documentation to process my request.

Date *

Exemption Appeal Process

Employees whose exemption request is denied may submit an Appeal for Denial of a Requested Exemption from the COVID-19 Mandatory Vaccination Policy within five (5) calendar days of the decision to rettrich@larkin.edu.

Employee Information

Exemption Request Type (Check One)

*Medical/ADA Disability Exemption Requests

Exemption Appeal Process

DIRECTORY

Stay In Touch

Handbooks

Policies

Copyright © 2022 Larkin University.
All Rights Reserved

Employee Information

Exemption Request Type (Check One)

*Medical/ADA Disability Exemption Requests

Exemption Appeal Process

DIRECTORY

Stay In Touch

Handbooks

Policies

Copyright © 2022 Larkin University. All Rights Reserved

Copyright © 2022 Larkin University.
All Rights Reserved