City of Los Angeles Employee Intent to File COVID-19 Vaccination Exemption Form
Pursuant to Ordinance 187134, COVID-19 Vaccination Requirement for All Current and Future City Employees, all current and future City employees, which includes volunteers, interns, hiring hall, appointed officers, board members and commissioners, 120-day retired employees, elected officials and at-will appointees of elected officials, shall have the right to petition for a medical or religious exemption from the mandatory vaccination requirement to be evaluated on a case-by-case basis, consistent with City procedures for reasonable accommodation requests. The Ordinance requires that requests for exemption from the COVID-19 vaccination be submitted no later than September 7, 2021, but this deadline was extended to September 13, 2021, and all exemption notices were required to be filed by that date.

All employees who were on leave during the time frame leading up to the September 13, 2021 deadline, including on September 13, 2021, may file a late notice of intent to file a COVID-19 medical or religious exemption if you have a City Employee ID Number. If you DO NOT have a City Employee ID Number, please use the form at this link: https://forms.gle/5iAaGikVFVprrWy38

The exemption procedures and forms can be found on the Personnel Department website: https://per.lacity.org/covid19.html. If you have any questions, please contact your department's HR personnel. Thank you!
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Email *
If you are a department's HR staff and are filling this form out on behalf of an employee who is unable to fill the form out directly, please enter your full name. If not, please skip this question.
First Name *
Last Name *
Department *
Employee ID *
City of Los Angeles Employee ID number. Please make sure this is correct, or we may not receive your submission.
Type of Vaccination Exemption *
Certification Statement
By submitting this form, you are certifying that the information you provided is true and correct and that you understand failure to provide truthful information can subject you to discipline. You also understand that you will need to provide the required exemption forms for review before your exemption can be approved. The exemption procedures and forms can be found on the Personnel Department website: https://per.lacity.org/covid19.html
A copy of your responses will be emailed to the address you provided.
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