![]() T he material in this sample policy is for general information purposes only. You should speak with your doctor or healthcare provider about whether COVID-19 vaccines are right for you. Health Action Alliance is committed to the health and safety of employees and communities. Health Action Alliance is committed to regularly updating our materials once we've engaged public health, business and communications experts about the implications of new guidance from the public health community and effective business strategies that align with public health goals. If Accommodation is not granted, explain why:ĭISCLAIMER : Public health guidance on COVID-19 is consistently evolving.If Accommodation is granted, list required alternative safety precautions required:.Interactive discussion date(s) if applicable: .Date this request form was received in Human Resources:.Signature: Date: Print Name: Part 2 - To be completed by Human Resources Representative face coverings, regular COVID-19 testing) for unvaccinated or not fully vaccinated individuals as a condition of my employment.] I also understand that my request for an accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on. I verify that the information I am submitting in support of my request for an accommodation is complete and accurate to the best of my knowledge, and I understand that any intentional misrepresentation contained in this request may result in discipline, up to and including termination. If requested, can you provide documentation to support your belief and the need for accommodation? YES NO If no, please explain why: We may need to discuss the nature of your sincerely held religious belief, observance, or practice, and accommodation with your religion’s spiritual leader (if applicable) or religious scholars to address your request for an exception. In some cases, will need to obtain additional information and/or documentation about your sincerely held religious belief, observance, or practice.Please describe the specific reasonable accommodation you are requesting from.Please briefly explain how long you have maintained your sincerely held religious belief, observance, or practice that conflicts with ’s COVID-19 Vaccination Policy and how it governs or impacts other aspects of your life.Company Name] ’s COVID-19 Vaccination Policy.Please briefly explain how your sincerely held religious belief, observance, or practice conflicts with ’s COVID-19 Vaccination Policy. ![]() Do you regard yourself as having a sincerely held religious belief, observance, or practice that you believe should exempt you from ’s COVID-19 Vaccination Policy? YES NO.Part 1 - To be completed by employee requesting accommodation If you have any questions about an accommodation or exemption request you made, please contact in the Human Resources Department. ![]() strives to make these determinations expeditiously and in a fair and nondiscriminatory manner and will inform you after we make a determination. makes determinations about requested accommodations and exemptions on a case-by-case basis, considering various factors and based on an individualized assessment in each situation. Refusing to provide the information requested in this form may impact ’s ability to adequately understand your request or effectively engage in the interactive process to identify possible accommodations. This information will be used by Human Resources or other appropriate personnel to engage in an interactive process to determine the precise limitations of your ability to comply with ’s COVID-19 Vaccination Policy and explore potential reasonable accommodations that could overcome those limitations. To request an accommodation related to ’s COVID-19 Vaccination Policy, please complete this form and return it to Human Resources. will provide reasonable accommodations for employees’ sincerely held religious beliefs, observances, and practices that conflict with getting vaccinated for COVID-19, as long as the requested accommodation does not create an undue hardship for or pose a direct threat to you or others in the workplace. As such, complies with all laws protecting employees’ religious beliefs and practices. Is committed to providing equal employment opportunities without regard to any protected status, and a work environment that is free of unlawful harassment, discrimination, and retaliation.
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