COVID-19 Vaccine Religious Accommodation Request

I,_Name

do hereby swear or affirm, that the following are true and correct: Employees may seek an accommodation from the COVID-19 vaccination mandate based upon a sincerely held religious belief, practice, or observance that prevents the employee from being vaccinated. To be eligible for an accommodation on religious grounds, you must attest that your refusal to be vaccinated is based upon a sincere belief that is religious in nature. Accommodation requests cannot be based upon personal preference, concerns about the possible effects of the vaccine, or social, political or economic philosophies.

You must initial each section below and fully complete this form to request a religious accommodation:

You must initial each section You must initial each section 1. I have a sincerely held religious belief, practice or observance which prevents me from receiving a COVID-19 vaccination and I am requesting an accommodation from receiving the COVID-19 vaccination based upon such belief, practice or observance. 2. I acknowledge if my request for exemption is granted, I will be subject to additional safety measures, which may include, among other things, additional testing, masking, and social distancing requirements, as well as potential reassignment based upon then applicable safety protocols. 3. I accept full responsibility for my health and health-related decisions, including my decision to seek an accommodation from Diamond Labor Solutions vaccination requirement. 4. I acknowledge that I have been given the opportunity to receive information from PAMHealth regarding the medical benefits and risks in choosing whether to obtain the COVID-19 vaccine. 5. I hereby release Diamond Labor Solutions and Pam Health and its employees from any responsibility for any impairment of my health resulting from this exemption, including but not limited to any claim related to COVID-19 should I become infected in the future, if my request for exemption is granted.

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