SCHOOL OF MEDICINE AND PUBLIC HEALTH
SEASONAL INFLUENZA VACCINE RELIGIOUS WAIVER
I decline the influenza vaccine due to my religious beliefs and convictions.
I attest that the information provided on this waiver is true to the best of my knowledge. I
understand that I should wear a mask when working in a patient care area within 3 feet of a patient
when there is the presence of influenza in the community as defined by the Hospital Epidemiologist.
Name of Employee (print): ________________________
ID #________________
Status:
Student
Employee
Volunteer
Religious Waiver: A religious waiver is allowed only if the influenza vaccination will violate
a central belief of your religion. Any such justification would need to be based in religion, not
science, and does not include fervently held beliefs regarding secular, cultural or political
matters. Please complete the information below to request a religious conviction waiver.
Your supporting statement will assist us in evaluation of this waiver request.
I certify that the influenza vaccination violates a central belief in my religion as to what is
right or wrong, and request a religious exemption based on the following reason:
Religious waivers do not need to be completed annually. However, if you chose to receive a flu vaccine after
completing a religious waiver, you will need to complete a new religious waiver if you want to waive the
vaccine in the future for religious reasons.
Signature
_________________________
_____
Date________________
Please return completed waiver form to SMPH Dean’s Office Human Resources, 4th Floor HSLC,
Fax: 608.262.9515
Reviewed 10.3.12