Form DS-5159 Request for a Religious Accomodation to the COVID-19 Vac

REQUEST FOR A RELIGIOUS ACCOMMODATION
TO THE COVID-19 VACCINATION REQUIREMENT  

Pursuant to guidance and instructions from the Office of Management and Budget (OMB),
the information requested below will be used to determine if the requesting Department of
State employee, onboarding employee, or candidate is entitled to a religious
accommodation.
Government-wide policy requires all Federal employees as defined in 5 U.S.C. § 2105 to
be vaccinated against COVID-19, with exceptions only as required by law.  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.  The State Department 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 the Department of State 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 full evaluation of your request. Where
there is an objective basis to do so, the Department of State 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.
The Department of State 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.

In order to request a religious exception, please fill out this form below.   
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 Federal Service. 
PLEASE PRINT OR COMPLETE  ELECTRONICALLY TO ENSURE LEGIBILITY 

Part I: To Be Completed by the Employee
Employee Last Name

Employee First Name

Employee ID: If you are an existing
employee:

Supervisor’s Name:

Employee State Email:

Employee Personal Email:

Part II: To Be Completed by the Employee
Current Gaining Office:

Bureau:

Position Title:

Part III: Questions to be completed by the Employee
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. How long you have held the religious belief underlying your objection?

4. Is your religious objection to the use of all vaccines, COVID-19 vaccines, a specific type of COVID19 vaccine, or some other subset of vaccines?

5. Have you received vaccines as an adult against any other diseases (such as a flu vaccine or a
tetanus vaccine)?

6. Please provide any additional information that you think may be helpful in reviewing your request.

7. Please provide any additional information that you think may be helpful in reviewing your request.

You must print, sign, and scan this document to send to [email protected].
I declare to the best of my knowledge and ability that the foregoing is true and correct. 
 Print Employee Name 

Employee Signature

Signature Date (mm/dd/yyyy)

Privacy Act Statement
Authority: The information is sought pursuant to Executive Order 14043, Requiring Coronavirus
Disease 2019 Vaccination for Federal Employees (Sept. 9, 2021); Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021); Executive Order
12196, Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980); Executive
Order 13163, Increasing the Opportunity for Individuals With Disabilities To Be Employed in the
Federal Government (July 26, 2000); Executive Order 13164, Requiring Federal Agencies To
Establish Procedures To Facilitate the Provision of Reasonable Accommodation (July 26, 2000);
and 5 U.S.C. chapters 11, and 79, 22 U.S.C. 4084, and 42 U.S.C. 12112(d).
Purpose: This information is being collected and maintained to promote the safety of Federal
buildings and the Federal workforce consistent with the above-referenced authorities, the COVID19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce
Task Force, and guidance from the Centers for Disease Control and Prevention and the
Occupational Safety and Health Administration. The information solicited on this form will permit the
Bureau of Global Talent Management to engage the individual in order to adjudicate requests for a
reasonable accommodation related to the COVID-19 vaccination requirement.
Routine Uses: While the information requested on this form is intended to be used primarily for
internal purposes, in certain circumstances it may be necessary to disclose this information
externally, for example to disclose information, where applicable, 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. Additionally, the information on this form
may be shared with consulting services that provide information about available aids, devices, and
methods of accommodating employees with disabilities; with the Department of Justice in connection
with proceedings before a court, adjudicative body, or other administrative body, if the information is
arguably relevant and necessary to the litigation; in response to an order from a court or
administrative body directing the production of such information; and to disclose information to Equal
Employment Opportunity (EEO) counselors and EEO investigators in connection with EEO
complaints and to the EEOC. A complete list of the routine uses can be found in the applicable
system of records notices associated with the specific type of information, including State-31, Human
Resources Records, 78 Fed. Reg. 43258 (July 19, 2013); OPM/GOVT-10, Employee Medical File
System of Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed. Reg. 74815 (Nov.
30, 2015); and State-24, Medical Records, 74 Fed. Reg. 24891 (May 26, 2009), amended 80 Fed.
Reg. 7671 (Feb. 11, 2015).
Disclosure: Providing this information is voluntary. However, failure to submit this form or provide
the information requested on this form may delay or impact a decision regarding your reasonable
accommodation request. All employees who do not submit appropriate documentation confirming
that they are fully vaccinated will be treated as not fully vaccinated and will be required to comply
with enhanced COVID-19 mitigation protocols, including mask wearing, physical distancing, travel
restrictions, and any testing protocol required by the Department, even if they have requested or
been approved for an accommodation.