Application for Medical or Religious Exemption to the COVID-19 Vaccine

Your Name:

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.

Employee Attestation

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, December 9, 2023

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Signature Certificate
Document name: COVID Attestation
lock iconUnique Document ID: 58688e27b352c77910397595967dc7ce5a4a8815
Timestamp Audit
April 13, 2023 4:49 pm ESTCOVID Attestation Uploaded by Assist Medical Staffing - IP
April 13, 2023 4:50 pm EST Document owner has handed over this document to 2023-04-13 16:50:09 -