Medical and Religious Exemption Request Form
Effective June 23, 2021, all employees must be fully vaccinated against SARS-CoV-2, also known as COVID-19. Please see here (
) for the full policy and procedure related to this requirement.
Exemptions are available to any employee who (1) has a disability or qualifying medical condition that contraindicates the vaccination or (2) who objects to being vaccinated on the basis of sincerely held religious beliefs and practices.
Requests for Medical or Religious exemptions should be submitted to the Office of Institutional Diversity and Equity (IDE) by using this secure form.
Medical Exemptions: Employees and appointees will be asked to provide documentation from their healthcare provider that states the nature and extent of any disability or medical condition that conflicts with the vaccination requirement, including why the vaccination is contraindicated because of the disabilty or medical condition, and the duration of the need for an exemption under this policy as it relates to the condition(s).
Religious Exemptions: Employees and appointees will be asked to provide a letter describing the basis for their request for a religious exemption from the vaccination requirement.
Sign in to Google
to save your progress.
Supervisor's name- needed only to communicate whether an exemption has been granted.
Your job title
Are you requesting a medical or religious exemption?
Never submit passwords through Google Forms.
This form was created inside of Dartmouth College.