COVID-19 VACCINATION RELIGIOUS EXEMPTION REQUEST
I. EMPLOYEE INFORMATION AND ACKNOWLEDGEMENT
Name:____________________________________ Banner ID: ________________________
Address: ____________________________________________________________________
E-mail: _______________________________ Cell Phone: ____________________________
Job Title: ____________________________ Campus/Department: ______________________
Immediate Management Supervisor: _______________________________________________
II. DESCRIPTION OF RELIGIOUS BELIEF, PRACTICE, OR OBSERVANCE (PLEASE
COMPLETE THIS SECTION)
For consideration of a religious exemption, you must provide all of the following:
A document from the religious organization to which you belong, supporting the
basis of the religious beliefs which are contrary to vaccination, signed by a
religious leader of the religion, and includes the name, address and phone
number/email of the religious leader.
OR
A statement signed and written by the employee (see space provided below)
Stating that you hold a religious belief contrary to you being administered
the COVID-19 vaccination
Demonstrating that your religious beliefs are genuinely and sincerely
contrary to you being administered the COVID-19 vaccination
Detailing the religious principles that form the basis of the objection to you
being administered the COVID-19 vaccination
IMPORTANT! A religious exemption will not be granted on a philosophical,
political, conscientious, or sociological beliefs, or personal preferences.
Please detail the religious principles that form the basis of your request for this religious
exemption. Describe your sincerely held religious belief(s), practice(s), or observance(s)
that conflict with NOCCCD’s requirement to you being administered the COVID-19
vaccination and be fully vaccinated:
Employee Signature:
For HR use only
Received: _________________ Approved Denied
Signature: __________________________________________ Date: ____________________