REQUEST FOR A RELIGIOUS EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT

Government-wide policy requires all Federal employees as defined in 5 U.S.C. § 2105 to be vaccinated against 

COVID-19, with exceptions only as required by law. In certain circumstances, Federal law may entitle a Federal 

employee who has a religious objection to the COVID-19 vaccination requirement to an exception from that 

requirement, in which case the employee would instead comply with alternative health and safety protocols. The 

Federal Government is committed to respecting the important legal protections for religious liberty. The purpose 

of this form is to determine whether you may be eligible for an exception.

To be eligible for a possible exception, you must first establish that your refusal to be vaccinated is based upon a 

sincere belief that is religious in nature. A refusal to be vaccinated does not qualify for an exception if it is based 

upon personal preference, concerns about the possible effects of the vaccine, or political opinions.

In order to request a religious exception, please fill out this form. The agency may ask for other information as 

needed to determine if you are legally entitled to an exception. 

Signing this form constitutes a declaration that the information you provide is, to the best of your knowledge and 

ability, true and correct. Any intentional misrepresentation to the Federal Government may result in legal 

consequences, including termination or removal from Federal Service.
QUESTIONS: 

1. Please describe the nature of your objection to the COVID-19 vaccination requirement. 

2. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise? 

If so, please explain how. 

3. How long have you held the religious belief underlying your objection? 

4. Please describe whether, as an adult, you have received any vaccines against any other diseases (such as a flu 

vaccine or a tetanus vaccine) and, if so, what vaccine you most recently received and when, to the best of your 

recollection. 

5. If you do not have a religious objection to the use of all vaccines, please explain why your objection is limited to 

particular vaccines. 

6. If there are any other medicines or products that you do not use because of the religious belief underlying your 

objection, please identify them. 

7. Please provide any additional information that you think may be helpful in reviewing your request. 

I declare to the best of my knowledge and ability that the foregoing is true and correct. 

Print name Employee signature Date 

Agency you work for: 

Supervisor name: 

Agency official action on request: Approve Deny 

Agency official remarks:

Agency officialsignature: Date:
Privacy Act Statement

Authority: We are authorized to collect the information requested on this form pursuant to Executive Order

13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), Executive Order 12196,

Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980), and 5 U.S.C. chapters 11, and

79.

Purpose: This information is being collected and maintained to promote the safety of Federal buildings and the

Federal workforce consistent with the above-referenced authorities, the COVID-19 Workplace Safety: Agency

Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from Centers for

Disease Control and Prevention and the Occupational Safety and Health Administration.

Routine Uses: While the information requested on this form is intended to be used primarily for internal

purposes, in certain circumstances it may be necessary to disclose this information externally, for example to

disclose information to: a Federal, State, or local agency to the extent necessary to comply with laws governing

reporting of communicable disease or other laws concerning health and safety in the work environment; to

adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent

necessary to carry out their authorized duties regarding Federal employment; to contractors, grantees, or

volunteers as necessary to perform their duties for the Federal Government; to other agencies, courts, and

persons as necessary and relevant in the course of litigation, and as necessary and in accordance with

requirements for law enforcement; or to a person authorized to act on your behalf. A complete list of the

routine uses can be found in the system of records notice associated with this collection of information, OPM/

GOVT-10, Employee Medical File System of Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed. Reg.

74815 (Nov. 30, 2015).

Consequence of Failure to Provide Information: Employees must certify under penalty of perjury that the

documentation they are submitting is true and correct. Providing this information is mandatory. If you fail to

provide this information within the requested timeframe, you will be subject to administrative action, up to

and including removal from Federal Service.