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NOTE TO EMPLOYER: This sample form can be used to request the need for a COVID-19 Vaccination accommodation due to a physical or mental disability. Employers can provide this form to the employee to have a physician or approved medical provider document the need for an exemption. The form can be modified to fit the needs of your organization.
To Whom It May Concern:
In response to the COVID-19 pandemic, our company has implemented a requirement for employees to be vaccinated against COVID-19. The employee mentioned below has requested an exemption from receiving the COVID-19 vaccination. We will consider requests when provided with documentation from a health care provider stating a health condition exists that would require accommodation under the Americans with Disabilities Act (ADA).