Fill - Free fillable Employee Request for Religious or Reasons of Conscience (University of Akron) PDF form

Employee Request for Religious or Reasons of Conscience Exemption

from COVID-19 Vaccine Form

Name:

UANET: Email: Phone:

SUBMIT COMPLETED FORM AND DOCUMENTS TO: EEOCompliance@uakron.edu

The University of Akron is committed to providing an inclusive and supportive environment for

all and recognizes true and genuine observance of faith as it pertains to the practice of

immunization. A religious or conscientious exemption may be granted if (i) the individual holds

sincere religious beliefs, practice, or observance that are contrary to the practice of vaccination

or holds a sincere moral or philosophical conviction, such as the conviction that health and

disease should not be controlled by vaccination, (ii) completes this form, and (iii) provides the

required documentation to support the exemption request.

If approved, the exemption will remain in effect for the duration of the current academic year.

Individuals with approved exemptions may request to recertify exemptions each year. Individuals

with an approved exemption may be required to comply with COVID-19 testing and other

preventive health and safety measures.

Your requests will be carefully reviewed, although approval is not guaranteed. After your request

has been reviewed and processed, you will be notified, in writing, if an exemption has been

granted or denied. The decisions are final and not subject to appeal. Individuals are permitted to

reapply if new documentation and information should become available.

In order to submit a request, please:

● Read the CDC COVID-19 Vaccine Information CDC COVID-19 Vaccine Information;

● Complete and sign this form;

● Complete and sign the Personal Statement Form; and

● Submit the completed documents.

Incomplete submissions will not be reviewed. Be sure all forms and documentation are

submitted at one time.

Initial next to each of the statements below:

I request exemption from the COVID-19 immunization requirement due to my

sincere religious beliefs or sincerely held reasons of conscience. I understand and

assume the risks of non-vaccination. I accept full responsibility for my health, and

the risk of serious illness and even death due to lack of vaccination and release

The University of Akron from any and all responsibility and liability.

Because I am not vaccinated, in order to protect my own health and the health

of the community, I will comply with all applicable COVID-19 testing

requirements and other preventive guidance issued by the University.

I understand that in the event of exposure to an outbreak or threatened outbreak,

I may be temporarily excluded or reassigned from The University of Akron’s

facilities and activities (including but not limited to University owned Residence

Halls).

I agree to comply with these restrictions and accept responsibility for

communicating with the University as appropriate to allow compliance with

health and safety requirements for unvaccinated individuals.

I further understand that restrictions from University facilities, including but not

limited to classes and living spaces, does not entitle me to any reduction in, ore

refund of tuition, housing charges, or other fees.

Should I contract COVID-19, I will immediately report it to The University of Akron

and comply with all isolation and quarantine procedures from Summit County

Health officials and the University.

I acknowledge that I have read the CDC COVID-19 Vaccine Information.

I understand and agree to comply with and abide by all of The University of Akron

COVID-19 policies and procedures, unless granted an exemption therefrom by the

University.

I understand that, if approved, this exception is only valid for the current

academic year, and I am required to resubmit a new request for any subsequent

academic year(s).

I certify that the information I have provided in connection with this request is

accurate and complete. I understand this exception may be revoked and I may be

subject to disciplinary action if any of the information I have provided in support

of this exemption is false.

Printed Name: Date:

Signature:

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Religious or Reasons of Conscience Exemption from COVID-19 Vaccine

Personal Statement Form

Name:

UANET: Email: Phone:

In the space below, please provide a personal written and signed statement explaining your

religious belief or reason of conscience as it pertains to your objections to vaccination, the basis

for that belief and how the University’s vaccination requirement would violate that religious

belief or reason of conscience. Please attach additional documentation, if necessary

I certify that my statement above is true and accurate and that I hold a sincere religious belief or

sincere reason of conscience that is against the receipt of the COVID-19 vaccination.

Printed Name:

Signature:

Date:

TO BE COMPLETED BY NOTARY PUBLIC:

Signature and Seal of Notary:

Subscribed and sworn before me on the day of , 2021

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