COVID-19 Vaccination: Religious Exemption Request
COVID-19 Vaccination: Religious Exemption Request
I am a:
*
Partner (Employee)
New Hire
Contractor/Agency/Temp
Vendor
Volunteer
Volunteer Practitioner
Medical Student
Intern/Student
Resident
Fellow
Partner East (Union)
Your Full Name:
*
Your Employee ID#: (numbers only)
*
Phone:
Phone:
*
-
###
-
###
####
Your Personal Email:
*
Your Mercyhealth Email:
*
Mercyhealth policy requires all partners to be vaccinated against COVID-19, with exemptions only as required by law. In certain circumstances, partners may hold a religious belief objection to the COVID-19 vaccination requirement. In this case the employee would instead comply with alternative health and safety protocols. Mercyhealth is committed to respecting the important legal protections for religious exemptions. In order to request a religious exemption, please fill out this form. The purpose of this form is to start the exemption process and provide information to Mercyhealth determine whether you may be eligible for a religious exemption. You do not need to answer every question on the form to be considered for a religious exemption, but we encourage you to provide as much information as possible to enable the agency to evaluate your request. If needed to further clarify the request, Human Resources may ask you for additional information as needed to determine if you are legally entitled to an exemption. Mercyhealth may consider several factors in assessing whether a request for an exemption is based on a sincerely held religious belief, including whether the partner has acted in a manner inconsistent with their professed belief. No one factor is determinative, rather, an individual’s beliefs—or degree of adherence—may change over time. Therefore, a partners newly adopted or inconsistently observed practices may nevertheless be based on a sincerely held religious belief. All requests for a religious exemption will be evaluated and considered on an individual basis. I understand that this religious exemption request and approval status will not exempt me from the Wellness Deduction. 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 of a religious declaration to Mercyhealth may result in disciplinary action leading to and including termination. 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)
Please respond below:
*
I attest that the information presented in this document is true and correct to the best of my knowledge. By signing this form I understand that the wage deduction of $27.69 per pay period will still remain in place.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
I attest that the information presented in this document is true and correct to the best of my knowledge. 1. Payroll Authorization. By signing below, you agree that: a. Mercyhealth has made the COVID 19 vaccination available to you free of charge; b. You are choosing not to be vaccinated for COVID-19 at this time; and c. You authorize Mercyhealth to deduct from your pay the dollar amount, which is $27.69 on a per pay period basis, as a result of your choice. The deductions will not exceed the amount allowed by law, but will continue until you provide proof of COVID-19 vaccination or end employment or withdraw this authorization in writing. 2. Applicable Laws. If this authorization conflicts with applicable laws where you are performing work for Mercyhealth, then the applicable law will control. In such event, this authorization will be enforced to the furthest extent permissible under applicable law. If the law changes and requires health care workers to be vaccinated, the option for you to remain unvaccinated may be discontinued. I freely agree that Mercyhealth may deduct money from my pay under the above circumstances, or if any of the above situations occur.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.