Please note that a request is not an approval. After your request has been reviewed and processed, you will be notified, in writing, if an exemption has been granted or denied. Please note that failure to submit completed forms will result in a denial of your request.

Please be prepared to offer proof of exemption within this request.

If you have been previously approved for a sincerely held religious belief exemption, your approval is still valid and recorded.

What Type of Exemption Are You Filing For?*

Medical ExemptionReligious Exemption

Status At ARH*

Date of Birth*

Please Specify "Other" Status At ARH*

Are you a Licensed Independent Practitioner (MD, DO, APRN, PA, etc.)?*

YesNo

ARH Employee Number *

Your Full Name*

Email*

Please enter a valid email address.

Your Phone Number*

Please enter a valid phone number.

Primary Work Location*

Please Specify "Other" Community*

Request for Medical Exemption from Influenza Vaccine Form (see attachment)

ARH requires all employees, students, volunteers, contractors and providers (including non-employed) who provide care or services within ARH facilities or clinics to receive the 2023-2024 influenza vaccination by December 31, 2023 unless granted a legally required exemption.

ARH is committed to complying with all laws protecting individuals with disabilities or medical conditions. When requested and required by law, ARH will provide an exemption/reasonable accommodation for any known medical condition or disability of a qualified individual which prevents the requestor from receiving an influenza vaccine, provided the requested accommodation is reasonable and does not create an undue hardship for ARH and/or pose a direct threat to the health or safety of others in the workplace and/or to the requesting employee.

A medical exemption may be granted upon receipt of a completed form (below) not more than 6 months old, signed and certified by a licensed health care provider, whose specialty is appropriate to the associated condition.

Medical exemptions expire when the medical condition(s) contraindicating influenza vaccination changes in a manner which permits vaccination. The assigned expiration is at the sole determination of ARH.

Individuals with an approved exemption may be required to comply with other preventive requirements and may be updated by later notification and/or posting of requirements on the ARH website.

ARH will carefully review all requests for medical exemptions, approval is not guaranteed. After your request has been reviewed and processed, you will be notified, in writing, if an exemption has been granted or denied. If the approved exemption contains an expiration, you will be expected to complete the vaccination requirement at that time. Should the condition continue, or a new vaccination contraindication occur, a new request with updated documentation is required.

Medical exemption process:

● Complete and electronically sign the following page of this form;

● Have your Licensed Health Care Provider complete the provider section of this form;

● Submit the completed documents.

Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time.

IF YOU HAVE NOT HAD THE

"Request for Medical Exemption from Influenza Vaccine Form"

FILLED OUT BY A MEDICAL PROFESSIONAL YOU WILL NOT BE ABLE TO APPLY

DOWNLOAD BELOW

CLICK HERE TO DOWNLOAD REQUEST FOR MEDICAL EXEMPTION FROM INFLUENZA VACCINATION

Proof of Exemption (Please Upload Your "Request for Medical Exemption from Influenza Vaccine Form" As Proof:*

Request for Religious Exemption from Influenza Vaccine Form

ARH requires all employees who work within ARH to receive influenza vaccination by December 31, 2023 unless granted a legally required exemption.

ARH is committed to complying with all laws protecting religious beliefs and practices. When requested and legally required, ARH will provide an exemption/reasonable accommodation for the requestor’s religious beliefs and practices which prohibit the employee from receiving aninfluenza vaccine, provided the requested accommodation is reasonable and does not create an undue hardship for the Company or pose a direct threat to the health and/or safety of others in the workplace and/or to the requesting party.

ARH will carefully review all requests for religious exemptions, approval is not guaranteed. After your request has been reviewed and processed, you will be notified, in writing, if an exemption has been granted or denied.

Answer each of the statements below:

I request exemption from the influenza vaccination requirement due to my sincere religious beliefs. I understand and assume the risks of non-vaccination*

YesNo

I understand that as I am not vaccinated, in order to protect my own health and the health of the community, I will comply with assigned influenza preventive guidance.*

YesNo

I understand and agree to comply with and abide by ARH’s Influenza Vaccine policies and procedures.*

YesNo

I understand that, if approved, this exemption is provisional based on ARH’s current Influenza vaccination policy and is subject to change based on ARH requirements moving forward.*

YesNo

I certify that the information I have provided in connection with this request is accurate and complete as of the date of submission. I understand this exemption may be revoked and I may be subject to disciplinary action if any of the information I provided in support of this exemption is false.*

YesNo

Submitting this document electronically and that it is the legal equivalent of having placed my handwritten signature on the submitted document.*

YesNo

In the space below, please provide a personal written and signed statement detailing the religious basis for your vaccination objection, explaining why you are requesting this religious exemption, the religious principle(s) that guide your objections to vaccination, and the religious basis that prohibits the influenza vaccination. Please attach additional documentation, if necessary.*

Name of Religious Organization:*

Religious Organization Address:*

Sign Here*

Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time.

2023 Appalachian Regional Healthcare Influenza (Flu) Vaccination Exemption Request

If you have been previously approved for a sincerely held religious belief exemption, your approval is still valid and recorded.

Request for Medical Exemption from Influenza Vaccine Form (see attachment)

Incomplete submissions will not be reviewed. Be sure all forms and documentation are submitted at one time.

IF YOU HAVE NOT HAD THE

"Request for Medical Exemption from Influenza Vaccine Form"

FILLED OUT BY A MEDICAL PROFESSIONAL YOU WILL NOT BE ABLE TO APPLY

DOWNLOAD BELOW

Request for Religious Exemption from Influenza Vaccine Form