MAKE YOUR FREE Vaccine Exemption Form
What is a Vaccine Exemption Form?
When to use a Vaccine Exemption Form:
- You are an employer who is rolling out a Vaccination Policy and need a way to document employees who opt out.
- You are an employer with a Vaccination Policy and are hiring an employee who wishes to opt out of the policy.
- You are an employee who wishes to opt out of your employer's Vaccination Policy.
Sample Vaccine Exemption Form
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I, , personally appeared before the notary public and swear or affirm as follows:
. I am an employee of , located at , , , .
. I understand that the Department of Public Health has determined:
a. that the required vaccinations are necessary to prevent the spread of dangerous diseases among the people of this state;
b. that the required vaccinations are safe;
c. that a person who does not receive the required vaccinations is at risk of contracting those diseases; and
d. that a person who does not receive the required vaccinations is at risk of spreading these diseases to other persons
. I understand that, my exemption notwithstanding, I may be prohibited from working in person or subject to other accommodations during an epidemic or pandemic.
| By: ___________________________________ | Date: __________________ |
STATE OF ,
DISTRICT OF COLUMBIA, ss:
The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by , who is personally known to me or who has produced ________________________________ as identification.
Before me, a Notary Public (or justice of the peace) in and for said county, personally appeared the above named , ________________________________, and ________________________________, who acknowledged that they did sign the foregoing instrument, and that the same is their free act and deed. In testimony whereof, I have hereunto subscribed my name at ________________________________, this _____ day of ____________________, ______.
The foregoing instrument was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, ______ by , who is personally known to me or who has produced ________________________________ as identification.
This instrument was acknowledged before me on this _____ day of ____________________, ______ by .
Subscribed, sworn to and acknowledged before me by , the Employee, this ________ day of _____________.
On this _____ day of ____________________, ______, before me personally appeared , to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he/she executed same as his/her free act and deed.
On this _____ day of ____________________, ______, before me, ________________________________, personally appeared , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same as for the purposes therein contained.
On this _____ day of ____________________, ______, before me, the undersigned, Notary Public for the State of Vermont, personally appeared , to me known (or to me proved) to be the identical person named in and who executed the above affidavit, and acknowledged that such person executed it as such person's voluntary act and deed.
The foregoing instrument was acknowledged before me this _____ day of ____________________, ______, by .
In witness whereof, I hereunto set my hand and official seal.
Signature of person taking acknowledgment
Notary Public
_________________________________
Name typed, printed, or stamped
My commission expires _____________
Notary Address:
_________________________________
_________________________________
_________________________________
_________________________________
Vaccine Exemption Form FAQs
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Should I get my Vaccine Exemption Form notarized?
Having your form notarized may be required by your employer. Even if it isn't required, having your statement notarized can help it feel more official.
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What is a medical or religious exemption?
A medical or religious exemption will allow an individual to decide against getting a vaccine, even if a health-related guideline would have otherwise mandated that the individual be vaccinated. Medical exemptions are usually granted to those who have an underlying health condition, such as a weakened immune system or autoimmune condition, or those who may experience a severe allergic reaction to a vaccine. A religious exemption may be granted to those who do not want to get vaccinated because of opposing religious beliefs.
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How can employers accommodate those with a medical or religious exemption?
Accommodating those with a medical or religious exemption can come in many forms. It really depends on the individual's specific circumstances. To determine an appropriate accommodation, the employee, employer, and any other involved party (e.g. religious leader or healthcare provider) will have to initiate the interactive process, whereby all parties discuss the extent to which accommodation is needed. Accommodations can range anywhere from adjusting an employee's schedule to allowing the employee to work from home.
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Can employers deny a request for vaccine exemption?
An employer can deny a request for vaccine exemption if it would bring about “undue hardship.' This can broadly be defined as significant difficulty or cost, or accommodation that requires the business to fundamentally alter how the business operates. If you need to deny an exemption request, it is important to talk to a lawyer who can help you navigate any potential issues that may arise as a result.
