• Melissa
    Would you have any suggestions on how to fill out this form? This is a form the employer provided. Looking for an AIRTIGHT response as had a serious reaction to a flu shot 10 years ago but he needs a job. We are pretty scared to have to get it.

    INFLUENZA VACCINATION Religious Exemption Request FORM
    To improve the safety of our patients, coworkers and community COMPANY/HOSPITAL requires all employees and contracted staff to receive a flu shot by December 1, 2017.
    To be completed by the Employee:
    How long have you been practicing this belief:___________________
    My signature below affirms that my request for religious exemption from the influenza vaccination is based upon sincerely held beliefs and practices. I believe I should not receive the vaccination because: _________________________________________________________
    __________________________________________________________ …
    COMPANY/HOSPITAL reserves the right to confirm the information provided with your witness or religious leader. By signing this form, you hereby authorize COMPANY/HOSPITAL HR and Spiritual Care professionals to contact your religious leader regarding the beliefs that prevent you from receiving the influenza vaccination. If your request is not approved, you will be expected to receive the influenza vaccine.
    To be completed by the witness or religious leader.
    My signature below attests that I understand the above named individual’s religious belief and the reason that receiving the influenza vaccination violates those beliefs.
    _______________________________witness _______relationship
  • Joe
    Not an attorney. This is the best I've seen so far:
    I work in Healthcare and decline the flu every year:
    "To whom it may concern:
    Based on my recognized religious denomination in which the tenets and practices of my religious denomination conflict with immunizations, I am declining the influenza vaccine. My decision is supported by my deeply held religious principles and by legal precedent.
    Religious Principles:
    My family’s personal religious beliefs prohibit the injection of foreign substances into our bodies. To inject into my body, any substance which would alter the state into which I was born, would be to criticize our faith. To vaccinate myself would violate laws put forth by us in being responsible for my life and safety. Our objection is based on our lifelong, deeply guided spiritual beliefs based on scripture.
    We choose to boost our body's natural defenses by following strict immune-boosting diets, supplementing vitamins, and receiving plenty of sleep. We strongly believe in allowing our bodies to maintain and heal itself naturally. A strong immune system is the best defense in preventing illnesses.
    My long-standing declination of immunizations stance can be proven by documentation in state-approved standardized religious exemption forms. The first form being Florida's DH 681 form, issued on July 18, 2011 to my eldest son and then to my youngest son on January 22, 2014. Upon moving to this state, South Carolina's DHEC-1126 form was issued to them on January 20, 2015.
    Legal Precedent:
    My religious exemption to vaccination is given in the free exercise clause of the First Amendment that mandates state accommodation for members of religious groups who object to the vaccinations on religious grounds. This free exercise argument follows the logic that requiring me to perform a vaccination mandate is abhorrent to my religious beliefs and practices and places a significant and undue burden on my free exercise rights. It would be unconstitutional for a state to institute mandatory vaccinations without providing at least some form of religious exemption.
    Although many vaccines are now being recommended for adults of all ages, there are no mandates that force compliance. Where access to vaccination is provided by law or recommended by health officials, the provisions include the right to informed consent and the option to decline vaccines.
    The statutory language for state vaccine policy clearly states that religious exemption must be granted without question if vaccination conflicts with a person’s religious convictions. A religious objection may be expressly implied by religious denomination or it may be based on an individual’s own moral/spiritual conscience to live God’s Word.
    Agents acting on behalf of the state in vaccination matters are prohibited from requesting any administrative proof that explains the recipient’s religious belief or that proves membership in an "acceptable" or specific religion. Agents of the state authorized by mandate to implement vaccine policy are prohibited from questioning the validity of one's religious objection. The state may not discriminate between religious denominations and may not make judgments regarding religious convictions.
    The case is established with legal precedent at the US Supreme Court level. (United States Supreme Court in Sharon Levy vs. Northcourt cases and Frazee vs. Illinois Dept. of Security, 489 U.S. 829)
    To be in compliance with the requirements of these statutes, agents of the state may not require additional administrative proof of religious conviction (including name of church affiliation or letters from pastors) and may not question your religious beliefs, discriminate against religious beliefs or make judgments regarding exemptions.
    Please be aware that the Florida Supreme Court emphasized in Board of Health vs. Curry (1998) that any attempt to investigate a request for exemption clearly exceeds statutory authority.
    Please also note Title VII of the Civil Rights Act of 1964 and S.C. Code of Law Title 1, Chapter 32 South Carolina Religious Freedom Act and S.C. Code of Regs. 61-91, Section 1502, B.
    While I understand and respect the commitment of [enter you health care's facility here] mandatory flu vaccination as a means to maintain the safety of patients, team members, and visitors in a healthy environment, which I am completely in favor of, I simply cannot concede that forced vaccinations are the solution. It is unfortunate and objectionable that anyone should be forced to accept these risks against their will or face termination.
    I hope I have adequately shown that refusing vaccinations fits in with my overall lifestyle of respecting my body and by requiring me to receive this vaccine is requiring me to act in direct opposition to my conscience, and thereby contrary to my religious beliefs. The religious exemption forms noted above can be made available upon request.
    [your name]
  • jtresco25
    I work for a hospital and I just need to sign a form that says I decline the Flu shot and then of course have to suffer through wearing the mask for my 12 hr shift. I wasn't aware that the flu shot was mandatory anywhere. I'm not sure where the initial post is coming from, but you should also be able to claim medical exemption also.
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