Teammate Vaccine Exemption Request

  1. Access the RSFH Mandatory COVID-19 Vaccination Policy here. All RSFH Workforce Members are required to be fully vaccinated against COVID-19 by November 1. In general, the first shot should be provided by October 1. The second shot, if required based on the type of vaccine administered, must be provided by November 1.

    • All active RSFH Workforce Members are required to receive the flu vaccination annually between October 1 and December 1. Workforce members beginning between December 1 and March 31 annually, must complete or demonstrate compliance prior to hire/affiliation.

  2. Download/Print the Exemption Form: There are two exemptions to the mandatory COVID-19 vaccination(s) and the mandatory flu vaccination(s): a medical exemption and a religious exemption. If you believe you qualify for a medical or religious exemption and you are a RSFH Teammate, download/print the form below and take it to your Provider (medical exemption) or Religious Leader (religious exemption) for him/her to complete with you and sign.


  3. Complete the online Information below and upload your complete, signed exemption form (completed by both you and your medical provider or religious leader) in order to submit your request.

  4. You will be notified of exemption approval or denial via email.

Online Information * Please note, in order to upload your form, you will need to check at least one box on each line

Exemption request  (select at least one)  
Applicable Vaccines  (select at least one)  
 
Personal Information
First Name:*
Last Name:*
 
Employee Number:*
 
Phone Number:*
(###-###-####)
Email Address:*
 
Manager's Name :*
Work Location:*
Job Title:*
 
COVID-19 Vaccination Medical Exemption Information (Check all that apply)  
Expected Delivery Date
(mm/dd/yyyy):*
 
Influenza Vaccination Medical Exemption Information (Check all that apply)  
 
Provider's Name:*
 
Provider's Credentials (ex. MD):*
 
Provider's Office/Employer:*
 
Provider's Phone Number:*
 
 
Medical Exemption Form
Upload your completed Exemption Form signed by you and a medical provider here.
Forms that are incomplete will not be considered.
 
Official's Name:*
 
Religious Organization:*
 
Official’s Phone Number:*
 
 
Religious Exemption Form
Upload your completed Exemption Form signed by you and a religious provider here.
Forms that are incomplete will not be considered.
 
 

You must click "Submit" to submit your request.

  • I have read and understand the RSFH Mandatory COVID-19 Vaccination and RSFH Mandatory Influenza Vaccination(s) policies. I will abide by the policy and all other rules and directives of RSFH from time to time regarding COVID-19 and flu risk mitigation practices.
  • I attest that I believe that I qualify for a medical or religious exemption under the policy which should be considered by RSFH, and I certify that statements in the exemption request are true and correct to the best of my knowledge.
  • I understand that while RSFH will consider my request, approval is not guaranteed. Requests for exemptions will be considered on a case-by-case basis, and may be granted if they meet the criteria for the exemption, and do not pose an undue hardship on RSFH or pose a direct threat to the health and safety of others.
  • I authorize and consent to RSFH Teammate Health and its panel of reviewing providers to speak with my medical provider if additional information or clarification is necessary regarding my request for medical exemption.
  • I authorize and consent to the RSFH Mission Department and its review panel to speak with my religious leader or others who are aware of the religious belief or practice if additional information or clarification is necessary regarding my request for religious exemption.
  • Because the COVID-19 pandemic is ongoing and conditions are constantly changing, I understand that, if approved, no exemption is permanent. Any exemption granted under the policy is provisional and must be renewed periodically as provided in the policy, and may modified or withdrawn by RSFH based upon future conditions and public health information and guidance.
  • I understand that it is solely my responsibility to ensure I either receive an approved exemption or obtain the required vaccination(s) by the established deadline(s) in order to obtain/maintain employment/affiliation with Roper St. Francis Healthcare.
  • I am aware that I can contact TeammateVaccReview@RSFH.com with questions about Medical Exemptions or HREmployeeRelations@rsfh.com with questions about Religious Exemptions.
 
Type Your Name Here to Acknowledge:*
Date: 12/9/2021
 



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