Vaccine Exemption Request
Employee Name
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First Name
Last Name
Email
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example@example.com
Department
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Role/Title
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From which vaccine(s) are you requesting exemption?
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1. Given the fact that most faith groups do not preclude vaccinations, tell us about your own personal faith journey that prohibits you from participating in the vaccine requirement?
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2. How were you able to accept and reconcile with the other vaccine requirements the Health System already has in place as a condition of employment (varicella, rubeola, rubella)?
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3. Have you ever taken the this vaccine? If so, what was different about your religious beliefs at that time that allowed you to participate?
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4. What are some additional ways that your faith has impacted important decisions in your career and/or life?
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5. To ensure we are fully understanding your religious beliefs in opposition to vaccines, what in your faith or religious writings do you point to that support your personal beliefs in avoiding vaccinations?
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6. The Flu vaccine administered by ARHS does not utilize fetal cell materials in the research, development/testing or production of the vaccine. If your objection to the COVID-19 or other vaccine is related to the use of fetal cells in the development of the vaccine, have you researched and will not use other medications, cosmetics, and sweeteners that are known to utilize fetal cells in research, development, or production?
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Yes
No
If you answered 'yes' to question #6, please specify the medications or products you do not use.
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Submit
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