Vaccination Appeal Form

This form is only for individuals who submitted an exemption request to the Exemption Review Committee, and the Committee denied that request. Appeals must be submitted within 7 days of notification of the initial denial.

Name: Name: First Last
Position Title:
VUnetID:
Department:
Date of Request: Date of Request: / MM / DD YYYY
Immunization Type:

Immunization Type: Influenza MMR Varicella Tdap COVID-19
My appeal is for:

My appeal is for: Medical or allergy Religious or sincerely held spiritual belief
Medical or Allergy: Please describe in detail the nature of the medical/allergy reason that forms the basis for your appeal. Please only provide information that was not submitted in your original request.
Medical or Allergy Certification:

By my signature below, I acknowledge that I have read and fully understand the information on this form. I understand that VUMC requires all personnel to be vaccinated against influenza on an annual basis, unless granted an exemption. With knowledge of the above, I am requesting an exemption from the influenza vaccination for medical/allergy reasons.

I further attest that if I am granted an exemption, I will comply with the requirement that I wear a mask that covers the nose and mouth while I am in patient care areas (both procedural and diagnostic). I understand that masks will be required from the time influenza is detected in Davidson County until the end of influenza season (a duration of usually 6-8 weeks). The exact time frame will be determined on an annual basis by the Department of Infection Prevention and will be communicated in a separate notification.
Medical or Allergy Certification (COVID-19):

By my signature below, I acknowledge that I have read and fully understand the information on this form. I understand that VUMC requires all personnel to be vaccinated against COVID-19 unless granted an exemption. With knowledge of the above, I am requesting an exemption from the COVID-19 vaccination for medical/allergy reasons.

I further attest that if I am granted an exemption, I will comply with any requirements set out as part of that exemption. This may include the requirement to wear a mask in different areas of VUMC or situations such as group meetings. Additionally, you may be required to undergo COVID-19 testing.
Medical or Allergy: Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Religious or sincerely held spiritual belief. Please describe in detail the nature of the religious or sincerely held spiritual belief that forms the basis for your appeal. Please only provide information that was not submitted in your original request.
Religious or Sincerely Held Spiritual Belief Certification:

By my signature below, I acknowledge that I have read and fully understand the information on this form. I understand that VUMC requires all health care personnel to be vaccinated against influenza on an annual basis, unless granted an exemption. I certify that influenza vaccination violates the tenets of my religious or sincerely held spiritual beliefs, and that my beliefs - not my scientific or medical objection to vaccinations - are the motivation for my request.

I further attest that if I am granted an exemption, I will comply with the requirement that I wear a mask that covers the nose and mouth while I am in patient care areas (both procedural and diagnostic). I understand that masks will be required from the time influenza is detected in Davidson County until the end of influenza season (a duration of usually 6-8 weeks). The exact time frame will be determined on an annual basis by the Department of Infection Prevention and will be communicated in a separate notification.
Religious or Sincerely Held Spiritual Belief Certification (COVID-19):

By my signature below, I acknowledge that I have read and fully understand the information on this form. I understand that VUMC requires all personnel to be vaccinated against COVID-19 unless granted an exemption. With knowledge of the above, I certify I am requesting an exemption from the COVID-19 vaccination and that this vaccination violates the tenets of my religious or sincerely held/personal beliefs and that my beliefs – not my scientific or medical objections to vaccinations – are the motivations for my request.

I further attest that if I am granted an exemption, I will comply with any requirements set out as part of that exemption. This may include the requirement to wear a mask in different areas of VUMC or situations such as group meetings. Additionally, you may be required to undergo COVID-19 testing.
Religious or Sincerely Held Belief: Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Next Steps:

1. You will be notified of the decision and/or the proposed accommodation by November 1.
2. If you are granted an exemption, you will be required to wear a surgical mask during the influenza season when in patient care areas (procedural and diagnostic).
3. All appeal decisions are final. If your appeal is denied, you are required to document influenza vaccination by December 1 or you will be subject to consequences for non-compliance as outlined in the VUMC Immunization policy (OP 30-10-07).
Next Steps (COVID-19):

1. Submitting a request for exemption may delay your new hire start date or may impact your ability to meet the exemption deadline.

2. If the Exemption Review Committee denies your exemption request as a new hire, you must document compliance with all vaccinations including COVID-19 before your start date.

3. If the Exemption Review Committee denies your exemption request as a current employee, you must document compliance with COVID-19 before exemption deadline otherwise your continued employment may be impacted.

4. All appeal decisions are final. If your appeal is denied, you are required to document COVID-19 vaccination by the due date or you will be subject to consequences for non-compliance.

Vaccination Appeal Form

Vaccination Appeal Form

Medical or Allergy Certification:

Medical or Allergy Certification (COVID-19):

Religious or Sincerely Held Spiritual Belief Certification:

Religious or Sincerely Held Spiritual Belief Certification (COVID-19):

Next Steps:

Next Steps (COVID-19):