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Covid-19 Vaccine Exemption Declaration Form Template

Create a Compliant Exemption Document in Minutes

Whether you're a healthcare provider or an employer managing vaccine mandates, you may need a straightforward way to document vaccination exemptions. This Covid-19 vaccine exemption declaration form template helps you record a patient's reason for exemption clearly and efficiently. Easily customizable to fit various needs, it ensures you comply with guidelines, protects sensitive information, facilitates smooth communication, and saves time on administrative tasks. Explore this template to get started on your exemption process.

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Full name
Date of birth
Email address
Phone number
Organization or institution name
Employee or student ID (if applicable)
Your role/status
Employee
Contractor
Volunteer
Student
Visitor
Other
Please Specify:
Type of exemption requested
Medical
Religious
Sincerely held personal belief
Disability-related accommodation
Temporary medical deferral
Other
Please Specify:
If requesting a temporary deferral, requested end date
Briefly describe your reason for requesting an exemption
If requesting a medical exemption, name of the licensed healthcare provider authorizing or advising this request
Your prior COVID-19 vaccination status
None
1 dose
2 doses
3+ doses
Prefer not to say
I understand I may be required to follow alternative safety measures (for example, testing or masking) as a condition of access.
Yes
No
I understand that declining vaccination may increase my risk of illness and transmission.
Yes
No
I acknowledge that organizational policies may change and my exemption may be reviewed or reevaluated.
Yes
No
I certify that the information provided in this request is true and complete to the best of my knowledge.
Yes
No
I consent to the collection and processing of this information for the purpose of evaluating my exemption request.
Yes
No
I agree to provide additional documentation to support my request if asked.
Yes
No
Signature (type your full legal name)
Date of signature
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Paper art illustration representing a flu shot proof form for FormCreatorAI article.

When to use this form

Use this declaration when an employee, contractor, student, or volunteer seeks an exemption from a COVID-19 vaccination requirement. It helps HR, compliance, and program admins document the request, understand the reason (medical, religious, or other), and decide on safe accommodations. For informed refusal records, you may also reference the Vaccine waiver form. If someone previously consented or is switching status, compare details with the COVID-19 Vaccine consent form. When medical records or provider statements must be shared to confirm a contraindication, pair the request with a HIPAA Authorization form. Common scenarios include healthcare units, schools, frontline services, and vendors who need a clear, auditable record before granting masking/testing alternatives.

Must Ask Covid-19 Vaccine Exemption Declaration Questions

  1. What is the specific basis for your exemption (medical, religious, or other)?

    This directs the request to the right review path and ensures precise documentation. If medical, you can require a clinician statement that names the contraindication and expected duration.

  2. What is your role and primary work setting?

    Your duties and location determine exposure risk and the practicality of accommodations. This helps decide whether masking, routine testing, or remote work can reduce risk.

  3. Have you received or declined any COVID-19 vaccine doses? If so, list vaccine type and dates.

    History shows potential risk level and whether timing affects accommodations. It also prevents conflicts with prior records and supports audit readiness.

  4. Which accommodations are you requesting to reduce risk?

    Stating specific requests (masking, N95 use, testing cadence, reassignment, remote work) sets clear expectations. It lets reviewers assess feasibility and plan supplies and scheduling.

  5. Do you acknowledge the risks of remaining unvaccinated and agree to follow site safety policies?

    This creates an informed declination and accountability for precautions. For thorough documentation of refusal, you can also reference the Against medical advice form.

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