COVID-19 Vaccine Religious Exemption Request Form

Any individual in the State of Alabama who is subject to a requirement that he or she receive one or more COVID-19 vaccinations as a condition of employment may claim an exemption for medical reasons, because the vaccination conflicts with sincerely held religious beliefs, or both.

You may request a religious exemption from the COVID-19 vaccination by completing this form and submitting the form to your employer.

In the event your employer denies this request, you have a right to file an appeal with the Department of Labor within 7 days. Your employer will provide you with information on how to file an appeal.

First Name

Last Name

Mobile Phone

Personal Email Address

Employee Number (if applicable)

I am requesting exemption from the COVID-19 vaccine requirements for the following reason: (select below)

Additional Comments (optional)

Reset Signature

I hereby swear or affirm that the information in this request is true and accurate. I understand that providing false or misleading information is grounds for discipline, up to and including termination from employment. By declining vaccination, I acknowledge that I shall be required to wear a surgical mask at all times in any EAH facility; additionally, I may be asked to use other source control methods as deemed appropriate. If I fail to comply with the mask requirements or other source control methods as outlined in the COVID 19 Policy, then I shall be subject to disciplinary procedures. I understand that I can change my mind at any time and accept COVID 19 vaccination, if vaccine is available.

For questions or further guidance, please call Human Resources at (334) 528-4188.

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