Need form filled out. does not have to be big paragraphs for each section. Claiming religious exemption. fill each section out (pg 1-3). after reading each question just answer why religiously i am not able to get vaccinated. use

chs community human services

EMERGENCY BOARD OF DIRECTORS MEETING MONDAY, NOVEMBER I, 2O2I

l. Approval of the Covid Vaccination Protocol for CHS Employees

a, When President Biden mandated Covid vaccinations for all Federal employees, he further ordered it also applies to all Federal contractors. CHS has several Federal contracts which support our programs. CEO Everett McElveen worked with the law firm Blank Rome LLP, Pittsburgh, to develop this policy. The local attorneys worked with one of their firm attorneys in the Washington DC office who specializes in Covid-related issues.

b. As the Protocol provides, CHS employees who do not meet specified deadline for proof of vaccination or an approved medical or religious exemption will be separated from the organization.

c. lf CHS does not comply with the Federally mandated vaccine provrsions, we would likely lose our federal funds. Accordingly, the Board is requested to approve this Protocol.

Action ltem: To approve the CHS Covid Vaccination Protocol

Next Board Meetino: Thursdav. November 18. 2021. 4:OO PM

Covid Vaccination Protocol As of December 8th,2021., all Community Human Services (CHS) staffwill need to be fully

vaccinated due to our partnerships with federal/state and local entities which require us to comply with newly issued government orders mandating covid-19 vaccinations. Each employee of CHS will need to be fully vaccinated which means both doses of the ffizer or Moderna vaccine, or the single dose

Johnson & Johnson vaccine and receive their booster for Johnson & Johnson inoculation 2 months after the initlal dose.

Vaccine Specific lnformation

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t*o-dose vaccination given 21 days apart with this protocol the first dose cannot be

taken later than, Wednesday November 10th, 2021. The second dose due no later than Wednesdav December 1st. This dosing schedule & calculation does not include the two-week post vaccination period in which the antibodies become fully active, and after the two-week period the person is now considered fully vaccinated per CDC Covid Vaccination Guidelines. Please also consider the booster shot available 6 months after your last vaccination dose.

MOdgf na, a two-dose vaccination given 28 days apart with this protocol the first dose

cannot be taken later than, Wednesday November 3d, 2021. The second dose is due no later than December L't, 2021. This dosing schedule & calculation does not include the two-week post vaccination period in which the antibodies become fully active, and after the two-week period the person is now considered fully vaccinated per CDC Covid Vaccination Guidelines. Please also consider the booster shot available 6 months after your Iast vaccination dose.

JOhnSOn & JOhnSOn, a single dose vaccination-the last date with this protocol to

receive this vaccination is Novembel 24'h, m2L. This dosing schedule & calculation includes the two- week post vaccination period in which the antibodies become fully active, and the person is now considered fully vaccinated per CDC Covid Vaccination Guidelines. Please also strongly consider the booster shot recommended two months post vaccination.

Please notify People Operations of your vacclnation status/ plan to be vaccinated no later than Friday, October 29, 2021. You will also be required to submit your completed vaccination card to People

Operations, attention Jane Allen (ialle[email protected]). You must send a copy of your first vaccine dose

on or before the date that corresponds to your selected Covid 19 vaccination to People Operations. You

must send a copy of your completed Moderna or ffizer (2 doses), or your Johnson & Johnson

vaccination no later than Novembet 24,z0Z!,for lohnson & Johnson or December 1" for ffizer or Moderna, to People Operations.

lf you choose to seek a medical or religious exemption request, this submission will not negate

the compliance dates. Contact Jane Allen for copies of exemption request forms. We are requiring that all requests be submitted no later than wednesday November 3'd, 2021. This submission date will still allow you to appropriate time for a Covid 19 Vaccination if the request is not approved.

ICOMPAI{YI COVID-Ig VACCINE REQUIREMENT

RELIGIOUS EXEMPTION/ACCOMMODATION REOUEST FORM

Please print a copy of this form, complete all sections, sign, and email to xxxxxxxxxx.com. [COMPAI{YI HR will review and contact you to discuss and seek additional information and documentation, as needed.

Employee Name Employee ID #:

Department:

Phone Number:

Job Title.

This document affirms that the administration of the COVID-l9 vaccine conflicts with my religious faith tenants, practices and,/or my sincerely held religious beliefs, and that I am requesting an accommodation from the vaccination requirements currently in effect at [COMPANY].

Please identifu your sincerely held religious belief(s), observance(s), or practice(s) that explain why you are requesting this exemptior/accommodation and how long you have adhered to these belief(s), observance(s), or practice(s)?

Please explain what it is about your belief(s). observance(s) or practice(s) that prevent you lrom getting vaccinated for COVID-I9 and necessitates this request. Please attach any additional supporting documentation to this request form.

9002m.0000 I/1271 88739v. I

When did you first form the belief(s), observance(s) or practice(s) that form the basis for your

accommodation request regarding vaccination?

Have you received any vaccinations in the past (e.9. poliq influenza, DTaP, HPV, Hepatitis B)? (circle one) Yes No

If you have received any prior vaccinations, how do those vaccines differ from the COrlD-l9 vaccines in the context ofyour beliefs?

900200.00001 /1 271 88739v. 1

2

Have you taken any prescription or over-the-counter medication since forming the beliefs that

form the basis for your accommodation request regarding vaccination? (circle one)

Yes No

Ifyou have taken medication since forming yourbeliefs, how do those medications differ from the CO{D-19 vaccines in the context ofyour beliefs?

Identify the accommodation(s) you are requesting and the applicable time period.

Please provide any additional information that may be helpful in processing your religious exemption/accommodation request.

I confirm that the information I have provided is accurate and truthful to the best of my knowledge.

I also understand that dishonesty may result in disciplinary action, including employment

termination.

Signature: Date:

900200.00001/127188739v. 1

Employee Medical Exemption/Accommodation Request -COVID-19 Vaccine

COMPANY ("Company") is committed to providing equal employment opportunities and a place of employmentthat does not allow unlawful harassment, discrimination, and retaliation. Our Company is

committed to complying with all laws protecting individuals with disabilities or medical conditions- The

Company will review requests for an exemption/reasonable accommodation for any known medical

condition or disability of a qualified individual which prevents them from receiving a COVID-19 vaccine.

Requests will be approved when reasonable and that do not create an undue hardship for the Company

and/or pose a direct threat to the health or safety of others in the workplace and/or to the requesting employee.

To request an Exemption/Accommodation related to the Company's COVID-19 vaccination policy, please

complete Part 1 of this form, have your healthcare provider complete Part 2 (the certification portion), and return them to Human Resources. This information will be used by Human Resources or other appropriate personnel to engage in an interactive process to determine whether an employee is eligible for such exemption/accommodation and if so, to determine the reasonable accommodations which can

be provided that would enable the employee to perform the essential functions of their position

without posing a threat of harm to self or others. lf an employee refuses to provide such information, the employee's refusal may impact the Company's ability to adequately understand the employee's request or to effectively engage in the interactive process to identify possible accommodations.

ln order to be properly submitted, the request must include the written certification completed by a

licensed, treating medical provider, of one of the following:

1. The applicable CDC symptom or condition that makes receipt of the COVID-19 vaccine a medical risk, or

2. A statement that the physical condition of the person or medical circumstances relating to the person are such that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization with the COVID-19 vaccine.

900202.tr)221 I 1 2597 52O3v 2

SECTION l- Employee to Complete the Following:

Name:

Date of Request:

Type of Request and Reason:

Verification and Accuracv I verify that the information I am submitting in support of my request for an accommodation is

complete and accurate to the best of my knowledge, and I understand that any intentional misrepresentation contained in this request may result in disciplinary action.

I also understand that my request for an accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on the Company.

Signature:

Date:

Print Name:

9O02O2.U)221 / 125975203v .2

SECTION ll -Employee's Medical Provider to Complete the Following:

Company Name:

Employee Name:

Medical Provider:

COMPANY requires a COVID-19 vaccination. The employee listed above is requesting an

exemption from this vaccination requirement. A medical exemption from the COVID-19

vaccination may be allowed for certain recognized medical conditions.

Please complete the form below. Should you have any questions, please contact . Thank you.

The above pe6on should not be immunized for COVID-19 for the following reasons (Please

check all that apply.):

f_l History of previous allergic reaction to indicate an immediate hypersensitivity reaction to a

component of the vaccine-

l-l The physical condition of the person or medical circumstances relating to the person are such that immunization is not considered safe. Please indicate the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization with the COVID-19 vaccine.

I-_l other – Please provide this information in an attached explanation that describes the exemption in detail.

I certify that has the above medical condition and verify the request a

medical exemption from the COVID-19 vaccination.

Medical Provider Signature:

Date:

Print Name:

Address:

Phone number:

900202 0022 1 1 1 2597 5203v.2

SECTION lll – Company Review of Request/ HR Only:

Date this Request Form Received in

lnteractive Discussion Date(s) if applicable:

Exemption/Accommodation granted?

Describe Exemption/Accommodation:

.Yes _ No

lf Exemption/Accommodation granted, list required ahernative safety precautions required:

Name of Representative:

Signature of Representative:

Date:

9 00202. (n 22 U I 2 s 97 5203 .2