Date
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REQUEST FOR A RELIGIOUS EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Government-wide policy requires all Federal employees as defined in 5 U.S.C. § 2105 to be vaccinated against
COVID-19, with exceptions only as required by law. In certain circumstances, Federal law may entitle a Federal
employee who has a religious objection to the COVID-19 vaccination requirement to an exception from that
requirement, in which case the employee would instead comply with alternative health and safety protocols.
The Federal Government is committed to respecting the important legal protections for religious liberty.
In order to request a religious exception, please fill out this form. The purpose of this form is to start the
accommodation process and help your agency determine whether you may be eligible for a religious exception.
You do not need to answer every question on the form to be considered for a religious exception, but we
encourage you to provide as much information as possible to enable the agency to evaluate your request.
Where there is an objective basis to do so, the agency may ask you for additional information as needed to
determine if you are legally entitled to an exception. Objections to COVID-19 vaccinations that are based on
non-religious reasons, including personal preferences or non-religious concerns about the vaccine, do not
qualify for a religious exception.
Agencies may consider several factors in assessing whether a request for an exception is based on a sincerely
held religious belief, including whether the employee has acted in a manner inconsistent with their professed
belief. But no one factor is determinative. An individual’s beliefs—or degree of adherence—may change over
time and, therefore, an employee’s newly adopted or inconsistently observed practices may nevertheless be
based on a sincerely held religious belief. All requests for a religious exception will be evaluated on an
individual basis.
Signing this form constitutes a declaration that the information you provide is, to the best of your knowledge
and ability, true and correct. Any intentional misrepresentation to the Federal Government may result in legal
consequences, including termination or removal from Federal Service.
QUESTIONS:
1. Please describe the nature of your objection to the COVID-19 vaccination requirement.
2. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise or
conflict with your sincerely held religious beliefs, practices, or observances? If so, please explain how.
3. Please provide any additional information that you think may be helpful in reviewing your request. For
example:
• How long you have held the religious belief underlying your objection
• Whether your religious objection is to the use of all vaccines, COVID-19 vaccines, a specific type of
COVID-19 vaccine, or some other subset of vaccines
• Whether you have received vaccines as an adult against any other diseases (such as a flu vaccine or a
tetanus vaccine)
I declare to the best of my knowledge and ability that the foregoing is true and correct.
___________________________ ________________________________
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