ArkansasChildrensHospital

RequestforMedicalorReligiousExemptionfromInfluenzaVaccination

EmployeeName______________________________________DateofBirth______________

ArkansasChildrensHospitalismandatinginfluenzavaccinationforallofitsemployees,similartootherrequired
vaccinationssuchasMMR.YoumustapplyinpersonatEmployeeHealthOfficetorequesteithermedicalor
religiousexemption.Eachrequestforexemption,regardlessofthereason,willbeevaluatedindividuallybya
committeeincludingmembersfromHumanResources,EmployeeHealth,InfectiousDiseasesandPastoralCare.

Medicalexemption__________
IunderstandthatbyrequestinganexemptionduetomedicalcontraindicationsIwillberequiredtoprovide
documentationfrommyprimarycarephysician.Ialsounderstandthatthemedicalexemptionmustbebasedon
standardcriteriaformedicalexemptionsrecommendedbytheCentersforDiseaseControlandPreventionor
AdvisoryCommitteesonImmunizationPractices.

Religiousexemption__________
IunderstandthatbyrequestinganexemptionduetoreligiousbeliefsIwillberequiredtoprovidedocumentation
statingthereasonsand/orreligiouspracticesthatdonotsupportimmunization.

IunderstandthatIwillbeprovided10businessdaystoobtainthesupportingdocumentationforeitherthe
medicalorreligiousexemption.

IunderstandthatIwillreceivewrittennotificationregardingstatusofexemptionrequestwithinfive(5)business
daysaftertherequireddocumentationhasbeenprovidedACHEmployeeHealthServices.

IunderstandthatifmyexemptionrequestisapprovedIwillberecognizedascompliantwiththemandatory
influenzavaccinationrequirement.Further,Iunderstandthatmyprotectedmedicalandreligiousinformationwill
bemaintainedinmyconfidentialEmployeeFileinHumanResources.Thisinformationwillnotbeprovidedto
anyoneoutsideoftheReviewCommitteeorHumanResourcespersonnel.

IunderstandthatIwillbeexpectedtofollowinfectioncontrolguidelinesandcareforpatientsadmitted/seenwith
influenzalikeillnessasmyjobdutiesrequire.Iwillfollowtransmissionbasedprecautionsforpatientswith
symptomsofinfluenzalikeillness.IunderstandthatifIdevelopaninfluenzalikeillness,Imustreportto
EmployeeHealthforpotentialworkexclusionuntilresolutionofsymptoms.

Foranyquestionsconcerningtheseexemptionspleasecontact,EmployeeHealthServicesatext.41219orthe
VicePresidentofHumanResourcesatext.44294.

________________________________________ ________________________________
EmployeeSignature Date

HumanResources
J.Holland,ext.4544;A.Trosclair,ext.44294
LastRevised:8/1/11