Fillable COVID-19 Vaccine Religious Exemption Request City of Chicago (City of Chicago)

Fill Online, Printable, Fillable, Blank COVID-19 Vaccine Religious Exemption Request City of Chicago (City of Chicago) Form

Use Fill to complete blank online CITY OF CHICAGO (IL) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COVID-19 Vaccine Religious Exemption Request City of Chicago (City of Chicago)

On average this form takes 7 minutes to complete

The COVID-19 Vaccine Religious Exemption Request City of Chicago (City of Chicago) form is 3 pages long and contains:

  • 3 signatures
  • 0 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Chicago

BROWSE CITY OF CHICAGO (IL) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Exhibit B
City of Chicago
COVID-19 Vaccine Religious Exemption Request
Return Certifications to:
Department of Human Resources
Email: vaccineexemptions@cityofchicago.org
Instructions for Employee
The City of Chicago is committed to providing equal employment opportunities without regard to any
protected status and a work environment that is free of unlawful harassment, discrimination, and
retaliation. As such, the City is committed to complying with all laws protecting employees’ religious beliefs
and practices. When requested, the City will provide an exemption from mandated vaccination for
employees’ religious beliefs and practices which prohibit the employee from receiving a COVID-19 vaccine.
• To request an exemption from the City of Chicago’s Mandatory COVID-19 Vaccination Policy due to a sincerely
held religious belief conflicting with any of the currently available COVID-19 vaccines, you must complete this
request form.
• The completed request form must be provided to the Department of Human Resources (email address:
vaccineexemptions@cityofchicago.org) or your department’s Human Resources Liaison in order to allow the
City to evaluate your religious exemption request. This information will be used by the Department of Human
Resources to engage in an interactive process to determine eligibility.
• Consistent with State and Federal law, exemptions will only be granted for a sincerely held set of moral
convictions arising from belief in and relation to religious beliefs.
• Failure or refusal to provide a complete and sufficient request form and/or engage in an interactive process with
the Department of Human Resources, if necessary, may impact the City’s ability to adequately understand your
request or effectively engage in the interactive process which may result in a denial of your exemption request.
• All COVID-19 Vaccine Religious Exemption Requests will be reviewed on a case-by-case basis, taking into
account whether the exemption would pose a direct threat to the health and/or safety of you, co-workers, or
members of the public during the course of your work duties or cause an undue hardship on the City’s
operations.
• Requests for exemption and any religious belief information provided will be kept confidential to the extent
possible and shared only with those City of Chicago employees who have a need to know.
• Any employee who is found to have engaged in misusing, abusing, and/or engaging in fraudulent activity in
requesting, certifying, or taking a religious exemption may be subject to discipline, up to & including termination.
Instructions for Religious or Spiritual Leader
• The City of Chicago requires that all employees receive the COVID-19 vaccination as a condition of employment.
However, a religious exemption from COVID-19 vaccination may be allowed due to an employee’s sincerely held
religious belief.
• Please review the employee’s completed attached certification.
• Please also read and complete Section III at the bottom of the attached certification.
• Be sure to sign the form and provide all requested contact information.
• You may return the completed form to the employee or send it directly to the vaccine exemptions inbox.
Exhibit B
City of Chicago
COVID-19 Vaccine Religious Exemption Request
Return Certifications to:
Department of Human Resources
Email: vaccineexemptions@cityofchicago.org
SECTION I: Employee Information (Please Print or Type)
Employee Name: _______________________________________ Department: ______________________________________
Job Title: _________________________________________________ Manager: _________________________________________
Daytime Phone: ________________________________________ Religion: ______________________________________________
I am requesting a religious exemption from the City of Chicago’s Mandatory COVID-19 Vaccination Policy.
By signing this form, I certify that the information I have provided is true and accurate to the best of my
knowledge. I understand that deliberately providing false or misleading information in support of my
request for religious exemption from the City of Chicago’s Mandatory COVID-19 Vaccination Policy or
refusing to engage in the interactive process with the Department of Human Resources regarding the
applied for exemption under the Vaccination Policy may result in disciplinary action, up to and including
termination, under the City’s Personnel Rules.
I further understand that in some cases, the City will need to obtain additional information and/or
documentation about my religious practice(s) or belief(s) or may need to discuss the nature of my
religious belief(s), practice(s) and accommodation with my religion’s spiritual leader (if applicable) or
religious scholars, to address my request for an exemption.
Employee Signature: _______________________________________________________________ Date: ___________________
SECTION II: Exemption Information
Please state your reason for requesting a religious exemption to the COVID-19 vaccine
requirement.
click to sign
signature
click to edit
Exhibit B
City of Chicago
COVID-19 Vaccine Religious Exemption Request
Return Certifications to:
Department of Human Resources
Email: vaccineexemptions@cityofchicago.org
What is the principle of your religious beliefs that conflicts with taking the COVID-19 vaccine? In
your response to this question, please include a description of the specific way that your religious beliefs prevent
you from being vaccinated.
When did you begin practicing this religion or following these beliefs?
Do your religious beliefs include objections to other vaccines or medications? If so, please explain.
Employee Signature:
Date (MM/DD/YYYY):
SECTION III: Religious or Spiritual Leader – Complete this section
Affirmation of belief: I have met with and provided religious or spiritual counsel to the above employee regarding their
sincerely held religious beliefs and practices. I affirm that this employee is a member of our religious organization. I further affirm
that these beliefs regarding any immunization or immunizing agent are in line with the tenets of our religious or spiritual faith,
teachings, and/or practices.
______________________________________________________
Religious or Spiritual Leader Name (Printed)
Date (MM/DD/YYYY):
Telephone #:
______________________________________________________
Religious or Spiritual Leader Signature
Email:
Religion:
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COVID-19 Vaccine Religious Exemption Request City of Chicago (City of Chicago)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 December 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document