3 Request Religious Exemption

REQUEST FOR A RELIGIOUS EXEMPTION
TO THE COVID-19 VACCINATION REQUIREMENT
The purpose of this form is to determine whether you may be eligible for a religious exemption to the
government-wide policy that requires all Federal employees, as defined in 5 U.S.C. § 2105, to be
vaccinated against COVID-19. An exemption is provided only as required by law. In certain
circumstances, a Federal employee who has a religious objection to the COVID-19 vaccination
requirement may be entitled under Federal law to an exemption from that requirement, in which case the
employee would instead comply with alternative health and safety protocols. The Federal government is
committed to respecting the important legal protections for religious liberty.
To be eligible for an exemption, you must first establish that your refusal to be vaccinated is based upon a
sincere belief that is religious in nature. A refusal to be vaccinated does not qualify for an exemption if it is
based upon personal preference, concerns about the possible effects of the vaccine, or political opinions.
To request a religious exemption, please fill out this form. If more space is needed, please attach documents
as necessary. The agency may ask for other information as needed to determine if you are legally entitled to
an exemption.
Signing this form constitutes a declaration that, to the best of your knowledge and ability, the information
you provide is true and correct. Any intentional misrepresentation to the Federal Government may result in
legal consequences, including termination or removal from Federal service.
Privacy Act Statement
Authority:
We are authorized to collect the information requested on this form pursuant to Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021); Executive Order 14043,
Executive Order on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (Sep. 9,
2021); Executive Order 12196, Occupational Safety and Health Program for Federal Employees (Feb. 26,
1980); and 5 U.S.C. chapters 11 and 79. Reasonable accommodation without undue hardship as required by
section 701(j) of Title VII of the Civil Rights Act of 1964, 42 U.S.C. § 2000e; 29 CFR § 1605.2; 5 U.S.C.
chapters 11 and 79.
Purpose:
This information is being collected and maintained to promote the safety of the Federal workforce and
Federal buildings, consistent with the above-referenced authorities, the COVID-19 Workplace Safety:
Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from
Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.
Routine Uses:
The information requested on this form is intended to be used primarily for internal purposes. However, in
certain circumstances it may be necessary to disclose this information externally. Examples include
disclosure to: a Federal, state, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the work environment; to
adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the

250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

extent necessary to carry out their authorized duties regarding Federal employment; to contractors, grantees, or
volunteers as necessary to perform their duties for the Federal government; to other agencies, courts, and
persons as necessary and relevant in the course of litigation, and as necessary and in accordance with
requirements for law enforcement; or to a person authorized to act on your behalf. A complete list of the
routine uses can be found in the system of records notice associated with this collection of information,
CNCS-10-CEO-PHRI, Personal Health and Religious Information (86 FR 6458).

Religious Exemption Request Tracking Number________________ (will be added after form is submitted)
Person Requesting Exemption

Date of Request

Office / Program

Work / Volunteer location

Position

Supervisor

Phone Number and Email Address

INFORMATION ABOUT YOUR EXEMPTION REQUEST
1. Please describe the be 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:

•

Is your religious objection to the use of all vaccines, COVID-19 vaccines, a specific type of COVID-19
vaccine, or some other subset of vaccines?

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Washington, D.C. 20525
202-606-5000 / 800-942-2677

•

Have you received vaccines as an adult against any other diseases, and if so, which (e.g., flu vaccine or a
tetanus vaccine)?

Requester’s Signature
I declare to the best of my knowledge and ability that the foregoing is true and correct.

Print Name

Date

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250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677