Name: Phone Number: Position/Job Title: Coordinator/Supervisor: E-mail Address:
1. Identify your sincerely held religious belief, practice, or observance that you believe specifically conflicts with the Company’s COVID-19 vaccination requirement:
2. Explain how your sincerely held religious belief, practice, or observance specifically conflicts with the Company’s COVID-19 vaccination requirement, and identify and describe the accommodation that you are requesting to eliminate the conflict, as well as any alternative accommodations that you believe will eliminate the conflict:
3. When did you begin following or subscribing to this religious belief, practice, or observance?
4. Would the religious belief, practice, or observance allow you to take the influenza, rubella , and/or hepatitis A vaccine, if it was required in order to work? And if so, why does the religious belief, practice, or observance allow you to take those vaccines but not the COVID-19 vaccine?
5. Please identify any sources, if any, that describe how your particular sincerely held religious belief, practice, or observance specifically conflicts with the Company’s COVID-19 vaccination requirement
