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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.

❖ 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: ____________________

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