Faculty and Staff COVID-19 Vaccine Policy Exemption Request

All Jacksonville University faculty and staff are required to be fully vaccinated against COVID-19 by October 1. Read more about the vaccine policy.

Responses to this form go to Allana Forte, Chief People and Culture Officer, at aforte@ju.edu.

Name Name * First Last
Email *
Phone Phone * - ### - ### ####
Title *
Division / Department *
Supervisor Name *
Senior Vice President Name
What is the basis of your request for exemption? *

What is the basis of your request for exemption? Medical: ADA Medical: Have had COVID in the last 90 days Religious / Faith-based Previously Approved for 100% Remote Work Other
Upload appropriate documentation for your request.

- Medical / ADA: A letter from your healthcare provider on their professional stationery confirming that you should not receive a vaccine due to a medical condition.

- Medical / COVID: A letter from your healthcare provider on their professional stationery confirming that you have had COVID in the last 90 days, or a positive COVID test from the last 90 days.

- Religions / Faith-based: A notarized letter from your faith leader or clergy member on letterhead associated with your body of worship.

- Previously Approved for 100% Remote Work: A copy of your remote work approval. *

Attach Files
On what grounds do you seek an exemption? *
I understand that Jacksonville University's vaccine policy permits exemption solely based on medical conditions or a religious/faith basis. I have chosen not to comply with the vaccine policy and would like to discuss next steps with the Office of People and Culture. *

I understand that Jacksonville University's vaccine policy permits exemption solely based on medical conditions or a religious/faith basis. I have chosen not to comply with the vaccine policy and would like to discuss next steps with the Office of People and Culture. I understand and affirm this statement.
In lieu of receiving the vaccine, will you agree to be tested for COVID-19 once per week indefinitely and to share confirmation of your test (name and date only, not the results) with your supervisor? *

In lieu of receiving the vaccine, will you agree to be tested for COVID-19 once per week indefinitely and to share confirmation of your test (name and date only, not the results) with your supervisor? Yes No
When did you test positive for COVID? When did you test positive for COVID? * / MM / DD YYYY
I understand and grant permission to the Office of People and Culture to inform my supervisor about my intent to pursue COVID-19 testing every seven days indefinitely and to provide them with documentation of my testing (name and date only, not the results). *

I understand and grant permission to the Office of People and Culture to inform my supervisor about my intent to pursue COVID-19 testing every seven days indefinitely and to provide them with documentation of my testing (name and date only, not the results). I understand and grant permission.