Form FMSHRC-09-001 Medical Exception Request to the Vaccination Requirement

Religious Exception Request to the Vaccination Requirement
In order to ensure the health and safety of the Federal workforce and the efficiency of the civil service,
full Coronavirus Disease 2019 Vaccination is now mandatory for all Federal employees, with exceptions
only required by law, under the new Executive Order 14043.
The Federal Government is also committed to respecting the important legal protections for religious
liberty. In certain circumstances, Federal law may entitle a Federal employee who has a religious
objection to the COVID-19 vaccination requirement to an exception from that requirement, in which
case the employee would instead comply with alternative health and safety protocols.
To be eligible for a possible exception, you must first establish that your refusal to be vaccinated is
based upon a sincere belief that is religious in nature. Objections to COVID-19 vaccinations that are
based on non-religious reasons, including personal preferences or non-religious concerns about the
vaccine, do not qualify for a religious exception.
The purpose of this form is to start the accommodation process and help your agency determine whether
you may be eligible for a religious exception. You do not need to answer every question on the form to
be considered for a religious exception, but we encourage you to provide as much information as possible
to enable the agency to evaluate your request. Where there is an objective basis to do so, the agency
may ask you for additional information as needed to determine if you are legally entitled to an exception.
Agencies may consider several factors in assessing whether a request for an exception is based on a
sincerely held religious belief, including whether the employee has acted in a manner inconsistent with
their professed belief. But no one factor is determinative. An individual’s beliefs—or degree of
adherence—may change over time and, therefore, an employee’s newly adopted or inconsistently
observed practices may nevertheless be based on a sincerely held religious belief. All requests for a
religious exception will be evaluated on an individual basis.
Signing this form constitutes a declaration that the information you provide is true and correct to the
best of your knowledge and ability. Any intentional misrepresentation to the Federal Government may
result in legal consequences, including termination or removal from Federal Service.

How to Use this Form
Part 1. Employee Information: You must complete all fillable forms.
Part 2. Questionnaire:

You must complete all questions on Pages 2 through 5 and electronically
sign the document on Page 5.
When completed, submit the form to our Reasonable Accommodations
Coordinator, Michael Chirico, at [email protected].

Privacy Act Statement
Authority:

Collection of the requested information is authorized by Title VII of the Civil Rights Act of 1964,
as amended, as implemented through 29 C.F.R. Part 1605. and 42 U.S.C. § 2000e, et seq. P

Purpose:

This information will be used to evaluate your request for religious accommodation.

Routine Use:

This information may be shared in response to a request for discovery or for appearance of a
witness, in response to a request for information that is relevant to the subject matter involved
in a pending judicial or administrative proceeding, or for routine uses identified in the Office of
Personnel Management’s system of records, OPM/GOVT-1 General Personnel Records.

Consequence of Failure to Provide Information:
Furnishing the requested information is required to establish that you have a need for reasonable
accommodation. Failure to fully complete the form or refusal to provide the requested
documentation may lead to a breakdown in the reasonable accommodation process and could
result in a determination that you are not entitled to reasonable accommodation.

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Part 1. Employee Information
Employee Name:

Date of Request:

Work Email:

Work Phone Number:

Office Location:

Department:

Position:

Supervisor:

Part 2. Questionnaire
Q1. Please describe the nature of your objection to the COVID-19 vaccination requirement.

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Q2. Would complying with the COVID-19 vaccination requirement substantially burden your
religious exercise? If so, please explain how.

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Q3. Please provide any additional information that you think may be helpful in reviewing your
request. For example:
• How long have you 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, as an adult, any vaccines against any other diseases (such
as a flu vaccine or a tetanus vaccine)

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Employee Signature:

Today’s Date:

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