Fillable COVID-19 Vaccination Exemption Form Student Name Student ID (Ohio State University, Columbus)

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COVID-19 Vaccination Exemption Form Student Name Student ID (Ohio State University, Columbus)

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The COVID-19 Vaccination Exemption Form Student Name Student ID (Ohio State University, Columbus) form is 2 pages long and contains:

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1
COVID-19 Vaccination Exemption Form
Student Name Student ID Number Date of Birth
My current enrollment status is best described as:
Undergraduate student
Graduate student
Professional student
COVID-19 vaccination exemption request
Documented health-related contraindication. Please attach documentation from your treating
health care provider (physician, advanced practice provider, CNP) with this form for review by
Student Health Services.
Documented allergic reaction to an ingredient in the COVID-19 vaccine. Please attach
appropriate documentation of the allergic reaction from your treating health care provider
(physician, advanced practice provider, CNP) for review by Student Health Services.
Documented history of allergic reactions to other vaccines or other medical injections. Please
attach appropriate documentation of the allergic reaction provided by your treating health care
provider (physician, advanced practice provider, CNP) with this form for review by Student
Health Services.
Documented COVID-19 infection or a history of having received a COVID-19 monoclonal
antibody infusion within 90 days prior to the November 15, 2021 deadline. NOTE: you will be
eligible for a temporary exemption until after the end of the 90-day period and then required to
receive a COVID-19 vaccination within 14 days of the end of the exemption.
Religious (details required in next question). Requires notary.
Personal (details required in next question). Requires notary.
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2
Explanation for request (Note: If you are seeking an exemption for a medical reason,
please complete the university’s medical exemption process.)
Religious Exemption
For the religious exemption, this form must be notarized at the time of submission.
I, , am a student of The
Ohio State University and am seeking an exemption from the COVID-19 vaccine because of
the following sincerely held religious belief:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
In some cases, Ohio State may need additional information and/or documentation about your
religious practices or beliefs. As such, please provide the name and contact information of
your spiritual leader (if applicable):
__________________________________________________________________________
__________________________________________________________________________
Personal Exemption
For the personal exemption, this form must be notarized at the time of submission.
I, , am a student of The
Ohio State University and am seeking an exemption from the COVID-19 vaccine because of
the following sincerely held personal belief:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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3
By signing below, I verify that the information is complete and accurate to the best of
my knowledge, and I understand that any intentional misrepresentation contained in
this request may result in progressive discipline. I understand that if I am granted an
exemption, the fact that I have received an exemption may be shared with those at the
university who have a need to know. I further understand that decisions made regarding
exemption requests are final.
Student Signature Date
If under 18 years of age:
Parent/Guardian Signature Date
Print Name
For personal and religious exemption requests, a notary public must complete the
following.
REQUIRED FOR PERSONAL & RELIGIOUS EXEMPTION
ACKNOWLEDGEMENT CERTIFICATE
State of Ohio, County of_______________________ The foregoing instrument was
acknowledged before me on this ________________ (date) by __________________________
(name of person acknowledging).
(Notary Seal) ___________________________________
Signature of Notary Public – State of Ohio
My commission expires: ______________(date)
Submit documentation via the My BuckMD health portal
by the deadline of Friday, September 17, 2021.
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COVID-19 Vaccination Exemption Form Student Name Student ID (Ohio State University, Columbus)

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Completed 20 September 2021

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