Non-medical Vaccination Exemption Request

Non-medical COVID-19 Vaccination Exemption Request (1)

Immunization exemptions will be permitted under certain circumstances. Students seeking a non-medical COVID-19 vaccination exemption based on a sincerely held religious belief, must complete this form and include a statement detailing the reason for your request. Non-medical COVID-19 vaccination exemption requests will be evaluated on a case-by-case basis. Students who receive a non-medical COVID-19 vaccination exemption may be subject to exclusion from campus in the event of a vaccine preventable disease outbreak and may be required to take other health and safety measures including, but not limited to, participation in surveillance testing, quarantine, and mask-wearing.

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First Name*

Last Name*

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Student ID (People Soft #)*

Enter your 7-digit ID number. Only numbers are accepted. Do not enter your NetID.

UConn Email*

Please enter a valid UConn email address for full consideration.

Student Status - select your student status from the drop down menu*

Enrollment Status-select your enrollment status from the drop down menu*

Campus - select your home campus from the drop down menu*

Residential Status - select your residential status from the drop down menu*

Address (Residence Hall or Home)*

Please indicate specifically what you are requesting an exemption from*

In the space below please provide a statement detailing the religious basis for your vaccination objection, explaining why you are requesting this religious exemption, the religious principle(s) that guide your objections to the vaccination, and the religious basis that prohibits the COVID-19 vaccination. Please attach additional documentation, if necessary. UConn may need to discuss the nature of your religious belief(s), practice(s) and/or request for exemption with your witness or religious leader(s) (if applicable). If we need to do so, we will contact you. UConn may also request additional supporting documentation if needed.*

Please indicate the length of time you have practiced your religion, belief or observance preventing you from receiving the COVID-19 vaccination:*

Have you received immunizations in the past?*

If yes, when was the last time you received any kind of immunization(s)?

What kind of immunization(s) did you receive?

If yes to the previous question, please provide an explanation detailing any changes in your religion, belief, or observance that have occurred since your last immunization, or the reason(s) that you believe your religion, belief, or observance prevents you from receiving the COVID-19 vaccine:

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Consent

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By submitting this form, you certify that the information you have provided in connection with this request is accurate and complete as of the date of submission. You understand this exemption may be revoked and this may be considered a violation of The Student Code and/or the Temporary Health and Safety Procedures if any of the information you provided in support of this exemption is false. You further acknowledge that if your request is approved, you will receive an exemption from receiving the COVID-19 vaccine and will be required to comply with all of the following:

• Participate in regular surveillance testing as directed by your campus. Full instructions on how to submit testing will provided.
• Wear masks or face coverings in all indoor settings
• Medical quarantine after contact with a suspected or confirmed case of COVID-19
• Isolation for presumed or confirmed cases of COVID-19

Updates to these requirements may be made based on evolving University, state and federal public health guidance.

You understand that by submitting this form, if granted an exemption, your name and vaccination status will be shared to the extent necessary to ensure compliance with health and safety requirements for unvaccinated individuals. You agree to comply with these restrictions and accept the responsibility for compliance with all health and safety requirements.

Also by submitting this form, you understand and assume the risks of non-vaccination. You understand that COVID-19 vaccination is recommended to protect yourself, other UConn students, faculty and staff from COVID-19 and its complications, including serious illness and death. You hereby agree to comply with all safety measures listed in the preceding paragraph as well as any other necessary and reasonable safety measures.

I acknowledge that I have read the CDC Covid-19 Vaccine Information (https://www.cdc.gov/coronavirus/2019- ncov/vaccines/index.html)

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Non-medical Vaccination Exemption Request

Non-medical COVID-19 Vaccination Exemption Request (1)

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