Request for Medical Exemption From COVID-19 Vaccination

Before you submit this form you MUST have your physician fill out the medical exemption form and have it available to attach to this form: Medical Exemption Form

If you currently have an approved COVID vaccination exemption on file, approved 1/1/2023 through Today's Date, you will not need to renew your request at this time.

Are you applying for a renewal? *

Are you applying for a renewal? No Yes
Select which one that best fits you: *

Select which one that best fits you: Applicant Board Member Board Member - Women's College Student - Aultman College Student - Not Aultman Employee Contractor (Provides on-site services) Licensed Independent Provider Volunteer Vendor (Uses Reptrax) Other Non-Employed Healthcare Provider
Employee ID: *
Name: Name: * First Last
Date of Birth: Date of Birth: * / MM / DD YYYY
Company: *
Phone: Phone: * - ### - ### ####
Email: *
Will you be working in a Post-Acute area? *

Will you be working in a Post-Acute area? No Yes
Physician Name: *
Physician Phone: Physician Phone: * - ### - ### ####
Medical / Disability Certification for Vaccination Accommodation Form: *

Attach Files

Upload the form that your physician completed.
Declaration: *

Declaration: I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct and that any intentional misrepresentation contained in this request may result in disciplinary action. I also understand that my request for an accommodation may not be granted if it is not reasonable or if it creates an undue hardship on my employer.
Declination of Vaccination: *

Declination of Vaccination: I understand that due to my presence at a health care facility, I may be at risk of acquiring infection of COVID-19. In addition, I may spread COVID-19 infection to my co-workers, patients, colleagues, family, and others, even if I have no symptoms. This can result in serious infection, particularly in persons at high risk for infection or complications. I have received education about the effectiveness of vaccinations as well as the adverse events. I have also been given the opportunity to be vaccinated, at no charge to myself. However, I decline vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring COVID-19. If in the future I want to be vaccinated, I can receive vaccination at no charge to me. I attest that I will wear a mask at all times while at any Aultman, or Aultman affiliated property, and take any and all additional precautions required of me in accordance with Aultman’s Infection Prevention policies. I attest I will take any COVID-19 tests required by Aultman.
AHF Accommodations
If approved, you must adhere to all the following guidelines: • A surgical mask, at a minimum, must be worn at all times and prior to reporting to work. You are not permitted to wear a cloth mask. You can find a surgical mask at the main entrances of the facility. Additional masks can be obtained through your department. It is your responsibility to ensure you have masks prior to reporting to work. • If you are experiencing any symptoms, you must perform an electronic health assessment. To access your electronic health assessment, please go to the Aultman Employee Portal. Click on the “Employee Screening” button on the main page and proceed through the questions. • If you have a positive electronic health assessment, you may not report to work. You must contact Employee Health Services (EHS) for additional steps. EHS will advise you on return-to-work guidelines based on your COVID-19 testing results. • Continue to practice good social distancing • Continue to practice good cleaning and hand hygiene • Your exemption is only valid for one year and will need to be updated annually. Even if Aultman’s infection prevention policies are changed or discontinued, you must continue to adhere to the above strategies. We reserve the right to also include staggered shifts, modifications to the work environment, permitting telework if feasible or reassignment to a vacant position in a different workspace.
PAC Accommodations
If approved, you must adhere to all the following guidelines: • An NIOSH-approved N95 or face mask equivalent, at a minimum, must be worn at all times and prior to reporting to work. It is your responsibility to ensure you have masks prior to reporting to work. • If you are experiencing any symptoms, you must perform an electronic health assessment. To access your electronic health assessment, please go to the Aultman Employee Portal. Click on the “Employee Screening” button on the main page and proceed through the questions. • If you have a positive electronic health assessment, you may not report to work. You must contact Employee Health Services (EHS) for additional steps. EHS will advise you on return-to-work guidelines based on your COVID-19 testing results. • Continue to practice social distancing. • Continue to practice good cleaning and hand hygiene. • Your exemption is only valid for one year and will need to be updated annually. Even if Aultman’s infection prevention policies are changed or discontinued, you must continue to adhere to the above strategies. We reserve the right to also include staggered shifts, modifications to the work environment, permitting telework if feasible or reassignment to a vacant position in a different workspace.
Accommodation Acknowledgement *

Accommodation Acknowledgement I have read and agree to the accommodations as stated above
You will be notified of the decision and/or the proposed accommodation as soon as
administratively possible.

If you disagree with the decision or proposed accommodation, please contact Human Resources.
I have read and agree to the terms above: *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.