Form NSF Religious Reasonable Accommodation

NATIONAL SCIENCE FOUNDATION (NSF)
REQUEST FOR A RELIGIOUS EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Pursuant to Government-wide and NSF policy, all NSF employees, as defined in 5 U.S.C. § 2105, and other NSF staff (e.g.,
IPAs, fellows, student volunteers) are required to be vaccinated against COVID-19, with exceptions only as required by
law. In certain circumstances, Federal law may entitle an individual who has a religious objection to the COVID-19
vaccination requirement to an exception from that requirement, in which case the individual would instead comply with
alternative health and safety protocols. The Federal Government is committed to respecting the important legal protections
for religious liberty.
In order to request a religious exception, please fill out this form. The purpose of this form is to start the accommodation
process and help NSF determine whether you may be eligible for a religious exception. You do not need to answer every
question below on this 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. 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.
Agencies may consider several factors in assessing whether a request for an exception is based on a sincerely held religious
belief, including whether the individual 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 individual’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, to the best of your knowledge and ability,
true and correct. Any intentional misrepresentation to the Federal Government may result in legal
consequences, including termination or removal from service.
QUESTIONS: Please separately attach or submit a statement responding to the questions below with your signed form to
NSF’s designated point of contact for reasonable accommodations (i.e., the Disability Program Manager in the NSF Office
of Diversity and Inclusion (ODI), [email protected]).

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)?

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

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Signature

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Date

PRIVACY ACT STATEMENT
Authority: 5 U.S.C. 7902(d); Occupational Safety & Health Act (OSHA) of 1970, 29 U.S.C. 668(a); National Science
Foundation Act of 1950, Pub. L. 507-81; 29 CFR part 1904; 29 CFR 1910.1020 and 1960.66; Executive Orders 12196,
13991, and 14043; OMB Memoranda M-21-15 and M-21-25; Safer Federal Workforce Task Force, COVID-19 Workplace
Safety: Agency Model Safety Principles; and other authorities, including title VII of the Civil Rights Act of 1974, the
Rehabilitation Act, and Equal Employment Opportunity Commission (EEOC) regulations, as applicable. While this form is
voluntary, failure to complete it may result in denial of an exemption from vaccination or testing requirements and
disciplinary or other action for non-compliance with such requirements, including termination and removal from
service.
Purpose: NSF will use the information you provide to determine your eligibility for a legal exception to the vaccination
requirement due to a sincerely held religious belief. This information is being collected to assist NSF with maintaining a
safe and healthy workplace, including to protect individuals in NSF facilities and events from risks associated with a
public health emergency; to plan and respond to workplace and personnel flexibilities needed during such an
emergency; to facilitate NSF's cooperation with public health authorities; to perform contact tracing investigations and
provide exposure notifications to NSF staff or other individuals; and to comply with legal recordkeeping and reporting
requirements.
Routine Uses: In addition to authorized internal NSF use, the information you provide may be disclosed to contractors,
other Federal, State, local and other agencies, health departments, medical authorities, and other entities in connection
with health screening, contact tracing, statistical reporting, and other efforts to address the spread of communicable
diseases and/or a public health emergency. For a full list of routine uses, see NSF-78 (NSF Staff & Visitor Medical
Information), posted at https://www.nsf.gov/privacy/. If you use the services of the NSF Health Unit or other NSF
health programs, and this information is maintained as part of those health and medical records, additional routine uses
apply to those records. See NSF-79 (NSF Health Program Records), posted at https://www.nsf.gov/privacy/. See also
OPM/GOVT-10 (Employee Medical Files System Records), 75 FR 35099 (June 21, 2010), amended at 80 FR 74815 (Nov.
30, 2015).
PAPERWORK REDUCTION ACT STATEMENT
A federal agency may not conduct or sponsor a collection of information unless it displays a currently valid OMB control
number, which is XXXX-XXXX for this form. We estimate that completing the form, including the time to review
instructions, should take no more than one (1) hour to complete.