Sample Request for Medical Exemption from COVID-19 Vaccination Policy Form

REQUEST FOR MEDICAL EXEMPTION / ACCOMMODATION RELATED TO [COMPANY NAME’S] COVID-19 VACCINATION POLICY

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[Company Name] is committed to providing equal employment opportunities without regard to any protected status, and a work environment that is free of unlawful harassment, discrimination, and retaliation. As such, [Company Name] complies with all laws protecting employees with disabilities or medical conditions. [Company Name] will provide reasonable accommodations for any known medical condition or disability that prevents an employee from getting vaccinated for COVID-19, as long as the requested accommodation does not create an undue hardship for [Company Name] or pose a direct threat to you or others in the workplace. 

To request an accommodation related to [Company Name]’s COVID-19 Vaccination Policy, please complete Part 1 of this form, have your medical provider complete Part 2 (the certification portion), and return them to Human Resources. This information will be used by Human Resources or other appropriate personnel to engage in an interactive process to determine the precise limitations of your ability to comply with [Company Name]’s COVID-19 Vaccination Policy and explore potential reasonable accommodations that could overcome those limitations. Refusing to provide the information requested in these forms may impact [Company Name]’s ability to adequately understand your request or effectively engage in the interactive process to identify possible accommodations.  

[Company Name] makes determinations about requested accommodations and exemptions on a case-by-case basis, considering various factors and based on an individualized assessment in each situation. [Company Name] strives to make these determinations expeditiously and in a fair and nondiscriminatory manner and will inform you after we make a determination. If you have any questions about an accommodation or exemption request you made, please contact [Name] in the Human Resources Department.

Part 1 - To be completed by employee requesting accommodation 

EMPLOYEE ACKNOWLEDGEMENT

I verify that the information I am submitting in support of my request for an accommodation is complete and accurate to the best of my knowledge, and I understand that any intentional misrepresentation contained in this request may result in discipline, up to and including termination. [While my request is pending, I understand that I must comply with [Company Name]’s workplace safety standards (e.g. face coverings, regular COVID-19 testing) for unvaccinated or not fully vaccinated individuals as a condition of my employment.] I also understand that my request for an accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on [Company Name].

Signature: 
Date:
Print Name:

Part 2 - To be completed by Employee's Medical Provider

NOTIFICATION TO THE CERTIFYING MEDICAL PROVIDER

[Company Name] requires a COVID-19 vaccination as a condition of employment. The above-named employee is requesting an exemption from this vaccination policy. Accommodations to the COVID-19 Vaccination Policy may be allowed for certain recognized contraindications. Should you have any questions, please contact [Company Name representative] at [Company Name representative’s contact information]. Thank you.

Please check the appropriate box and describe below:

The contraindication, physical condition, or circumstance is: 

Part 3 - To be completed by Human Resources Representative

DISCLAIMER: Public health guidance on COVID-19 is consistently evolving. Health Action Alliance is committed to regularly updating our materials once we've engaged public health, business and communications experts about the implications of new guidance from the public health community and effective business strategies that align with public health goals. 

Health Action Alliance is committed to the health and safety of employees and communities. You should speak with your doctor or healthcare provider about whether COVID-19 vaccines are right for you.  

The material in this sample policy is for general information purposes only. This sample policy is not intended to be, and should not be construed as, legal, business, medical, scientific or any other advice for any particular situation. The content included herein is provided for informational purposes only and may not reflect the most current developments as the subject matter is extremely fluid and may change daily.   

Readers of this sample policy should contact their attorney to obtain advice with respect to any particular legal matter. No reader, user, or browser of this material should act or refrain from acting on the basis of information in this sample policy without first seeking legal advice from counsel in the relevant jurisdiction. Only your individual attorney can provide assurances that the information contained herein – and your interpretation of it – is applicable or appropriate to your particular situation.