Religious Accommodation As Inability To Be Vaccinated Against Covid-19 Request Form

Completion of this form and approval by EIU is required before an accommodation may be approved/continued.

Employee Name Employee Name * First Last
E-Number *
EIU Email *
EIU Phone Number EIU Phone Number * - ### - ### ####
Employee's Position *
In the space provided below, please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflict with receiving a COVID-19 vaccination. Your objection may be personal and need not be directed by the tenets of an established religious organization. General philosophical or moral reluctance to allow immunizations will not provide enough basis for an exception to the requirements. *
In space provided below, please provide list of vaccinations previously received. *
Draw your signature into the box below. *

Draw or Type

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Full Name

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