Application for Medical or Religious Exemption to the COVID-19 Vaccine
Employee Acknowledgement of Risk
I understand the risk associated with contracting the COVID-19 illness. I also understand that it is my responsibility to closely monitor my health and to stay away from work if I have a fever or any other symptoms of illness. Further, I commit to maintaining a lifestyle that supports optimum immune health and well-being. In the event of a COVID-19 case or outbreak at work, I agree to comply with my employer or state quarantine, or isolation procedures as recommended by the Center of Disease Control and Prevention (CDC) and state and local health departments. (please initial here)
Employee Explanation to Support Medical or Religious Exemption
Please use the space below to detail your position for declining the COVID-19 vaccination.
My signature below indicates that the information on this form is accurate and true.
Medical Professional or Pastoral Declaration
I attest that holds the medical condition/religious tenets as explained above.
Professional Signature: Charles Williams, RN, June 7, 2023
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: COVID Attestation
Agree & Sign