Request for Religious/Moral Exemption from COVID-19 Vaccine Form for Students

Request for Religious / Moral Exemption from COVID-19 Vaccine for Students

Any information provided on this form will remain confidential.
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CIA policy requires that all faculty, staff and affiliates receive a COVID-19 vaccination. A religious/moral exemption may be granted if (i) the individual holds sincere religious/moral beliefs that are contrary to the practice of vaccination, (ii) completes this form, and (iii) provides the required documentation to support the exemption request. CIA is committed to providing a safe, inclusive, and supportive experience for all and recognizes sincere observance of faith as it pertains to the practice of vaccination.

Religious exemptions must be requested annually. 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 requirements as specified in the exemption approval and as may be updated by later notification and/or posting of requirements on the CIA website. In the event of an outbreak on or near campus, individuals with exemptions may be excluded from all campus facilities and activities in order to protect all unvaccinated members of the CIA community until the outbreak is declared to be over.

CIA will carefully review each request and determine whether the request should be granted. After your request has been reviewed and processed, you will be notified, in writing, whether an exemption has been granted or denied. The decision is final and not subject to appeal. Individuals are permitted to reapply if new documentation and information should become available.

Important Note: Students religious/moral vaccination exemptions will be reviewed by the Dean of Students. Please note that requesting a religious immunization exemption does not equate to a workplace religious accommodation. If you require religious accommodations, please contact jlgrant@cia.edu for more information.

Religious exemption process:

● Read the CDC COVID-19 Vaccine Information;
● Complete and sign the following page of this form;
● Complete the personal statement form; and
● Submit the completed documents in our vaccine portal .

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 vaccination requirement due to my sincere religious/moral beliefs. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from CIA to the required vaccinations.
I understand that as I am not vaccinated, in order to protect my own health and the health of the community, I will comply with assigned COVID-19 testing requirements and other preventive guidance.
I understand that in the event of an outbreak or threatened outbreak, I may be temporarily excluded or reassigned from College facilities and approved activities (including but not limited to College-owned housing). I agree to comply with these restrictions and accept responsibility for communicating with supervisors, human resources, and/or Student Affairs as appropriate to allow compliance with health and safety requirements for unvaccinated individuals.
Should I contract COVID-19 or am exposed to COVID-19, I will immediately report it to CIA Human Resources and comply with all isolation and quarantine procedures specified by CIA and remove myself from the College community, if so advised.
I acknowledge that I have read the CDC COVID-19 Vaccine Information.
I understand and agree to comply with and abide by all CIA COVID-19 policies and procedures.
I understand that, if approved, this exemption is provisional based on the current CIA College COVID-19 vaccination policy and is subject to change based on College requirements moving forward.
I certify that the information I have provided in connection with this request is accurate and complete as of the date of submission. I understand this exemption may be revoked and I may be subject to disciplinary action under the Student Code of Conduct if any of the information I provided in support of this exemption is false.
Printed Name
Signature
Date

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Date
By checking this box and typing my name above, I understand and agree that I am submitting this document electronically and that it is the legal equivalent of having placed my handwritten signature on the submitted document.
Personal Statement
In the space below, please describe the religious, ethical or moral basis for your request for an accommodation that could exempt you from the COVID-19 vaccine requirement. Please attach additional documentation, if necessary.
I certify that my statement above is true and accurate and that I hold a sincere religious, moral or ethical belief that is against the receipt of the COVID-19 vaccination.

To the extent that CIA may potentially accommodate individuals who are unable to be fully vaccinated because doing so conflicts with their sincerely held religious beliefs or practices, CIA is likely to implement additional safety procedures, including masking obligations, physical distancing, and testing requirements. You acknowledge and agree that, if your request for an accommodation is granted, you would comply with such additional safety procedures as instructed by CIA. You also acknowledge that failure to comply with these additional safety procedures will result in referral to student conduct. Outcomes of students found responsible for violations of this policy will include, but are not limited to, fines.
Printed Name
Signature
Date

MonthDayYear
Date
IMPORTANT: SAVE THIS FORM AS A PDF PRIOR TO SUBMITTING. YOU WILL NEED TO UPLOAD THE PDF TO THE VACCINE STATUS FORM.
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Request for Religious / Moral Exemption from COVID-19 Vaccine for Students

Personal Statement

IMPORTANT: SAVE THIS FORM AS A PDF PRIOR TO SUBMITTING. YOU WILL NEED TO UPLOAD THE PDF TO THE VACCINE STATUS FORM.