Covid-19 Vaccine Policy Religious Accommodation Form

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In order to provide a safe work environment for employees and workplace visitors, [Employer] implemented a Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy.

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[Employer] complies with all federal, state, and local equal employment opportunity laws. In all hiring and employment practices, [Employer] makes every effort to ensure that it doesn’t discriminate against employees and applicants based on religious beliefs, observances, and practices and that it provides reasonable accommodations to employees and applicants for such beliefs, observances, and practices unless the accommodations create undue hardship for [Employer].

[Employer] will engage with employees requesting religious accommodations regarding the Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy to determine if a reasonable accommodation can be granted. Please provide the following information, which will help to determine possible reasonable accommodations that can be made:

Employee Name:

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Date:

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Employee’s Department:

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Employee’s Supervisor:

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Please describe the nature of your objection to the Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy.

____________________________________________________

Would complying with the Covid-19 Employer Vaccine Mandate [or Vaccine-or-Test] policy substantially burden your religious exercise or conflict with your sincerely held religious beliefs, practices, or observances? If so, please explain how.

____________________________________________________

Please provide any additional information that you think may be helpful in reviewing your request for accommodation (e.g. how long you have held this belief; whether the religious objection is to all vaccines, the Covid-19 vaccine, or a specific Covid-19 vaccine; whether you have received vaccines as an adult against other diseases like influenza).

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Religious accommodations suggested by employee (Optional):

____________________________________________________

I hereby declare that my religious beliefs are sincere and that the above described conflict(s) arise from such beliefs. I understand that [Employer] isn’t required by law to give me my suggested or preferred religious accommodation(s) as long as [Employer] provides me with a reasonable religious accommodation, if possible.

Signed:

______________

Employee’s Name:

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Date:

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