_{The employee indicated above is requesting to be exempt from influenza vaccination for religious reasons.  Please confirm that the employee follows religious beliefs that would qualify for an exemption by completing the information below:}  

_{Name of Religion:_______________________________________________________________________________}

_{Name and Address of Religious Organization:  ________________________________________________________}

_{_____________________________________________________________________________________________}

_{Clergy Signature:_________________________________________________   Date: _______________   Time:___________            (Signature only,  stamps not acceptable)
Requests for religious exemptions should be filed with the Office of Human Resources. If granted, employee
will be required to wear a mask while in defined patient care areas for the duration of the 2014-2015 Influenza season.  If you have any questions please call --------.}

_{_____________________________________________________________________________________________________________________________________________________}