Fillable COVID-19 Non-Medical Exemption Form (Oregon Institute of Technology)

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COVID-19 Non-Medical Exemption Form (Oregon Institute of Technology)

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The COVID-19 Non-Medical Exemption Form (Oregon Institute of Technology) form is 2 pages long and contains:

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  • 12 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Oregon Institute of Technology

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COVID-19 Non-Medical Exemption Form
Directions: Complete all sections. Anyone under 18 at the time of signing must obtain a guardian signature. The
completed form should be uploaded into the student health portal through TechWeb/MyHealth/My Health Portal
(students only) or submitted electronically to the Office of Human Resources at
OITHR@oit.edu
(employees only).
Section One: Name and Identifying Information
Last name: _____________________ First name: ___________________ Middle initial: _____
Oregon Tech ID# 918____________ Oregon Tech email: _____________________ @oit.edu
Phone: _____________________
Section Two: Non-Medical Exemption Request
In accordance with Oregon law (OAR 333-050-0040 and ORS 433.284), an employee or
student can decline the COVID-19 Vaccine due to religious, philosophical, or other deeply
held beliefs; or other personal reasons, including but not limited to an informed decision to
wait for one of the vaccine options to have full FDA approval.
Please describe in sufficient detail the basis for the requested Non-Medical exemption:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
In order to receive an approved Non-Medical Exemption, you are required to view an
Oregon Health Authority or Oregon Tech sanctioned COVID-19 vaccine educational module
which provides information about the vaccine, as well as reviewing common myths,
benefits, and risks of immunization.
I confirm that I have viewed the Oregon Health Authority or Oregon Tech sanctioned
COVID-19 educational module as required.
(Continued on Page Two)
Click here to view the educational module
Section Three: Acknowledgment & Declination
COVID-19 is a highly contagious respiratory virus that affects people of all ages. This virus can
cause long-term medical problems and death regardless of age. This virus spreads through
respiratory secretions related to speaking, singing, yelling, coughing, and sneezing. Infected
individuals can spread the virus to others. Up to 50% or more of people can be infected without
realizing it. The COVID-19 vaccines are highly effective at preventing death and hospitalization.
When large numbers within a population are immunized, viral spread will be significantly limited.
Each individual of a community can contribute to this protective approach.
I understand that while Oregon Tech will take reasonable measures to mitigate the spread of
COVID-19 on-campus, the University cannot protect any individual from all risks associated
with contracting the virus. I have received information regarding the benefits and risks of
immunizations through the educational video. I understand that choosing to forego vaccination
puts me at risk for getting the disease with the associated risk of long-term medical problems or
death. In order to minimize risk of viral spread, I understand that I may be required to undergo
testing for COVID-19 should I develop symptoms. I understand that if I contract the disease, I
will need to enter isolation for a period of typically ten days, during which time I will not be able
to come to campus. I further understand that as an unvaccinated individual, if I am exposed to
someone with COVID-19, I will be required to quarantine for 14 days (or other time period per
CDC guidelines) -- and if I develop COVID-19 during my quarantine, my time in isolation could
be extended by an additional ten days. With a full understanding of this information, I request to
decline Oregon Tech’s Vaccination Requirement, and I accept the potential consequences
associated with this decision.
Signature: _________________________________ Date: ________________
If under 18, signature of guardian: ________________________________ Date: __________
If you have questions about this form, contact the following:
Students – Integrated Student Health Center, 541-885-1800
Employees – Human Resources, 541-885-1074
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COVID-19 Non-Medical Exemption Form (Oregon Institute of Technology)

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Completed 7 October 2021

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