COVID-19 Vaccine Religious Exemption Request | Office of Clinical Placement Coordination

Use this form to submit a religious exemption request for the COVID-19 vaccine or booster. Once submitted, your request will be forwarded to the Dean of Students office for review. If your request is approved, you will receive an email from the Dean of Students office within 7-10 business days. Remember that not all agencies will accept exemptions for the COVID-19 vaccine requirement. UConn is not responsible for placing students who do not meet agency requirements. Note that this form is only for religious exemption requests. If you need to submit a medical exemption request, please follow the medical exemption instructions provided on the COVID-19 page.

Name(Required)

First Last

Student ID (PeopleSoft#)(Required)

UConn Email(Required)

Program(Required)

For which component(s) are you seeking an exemption?(Required)

I seek a religious exemption for the full COVID-19 vaccine.

I seek a religious exemption for the COVID-19 booster only.

Please provide a statement detailing the religious basis for your vaccination objection. Explain why you are requesting this religious exemption, the principle(s) that guide your objections to the vaccination, and the religious basis that prohibits the COVID-19 vaccination. UConn may request additional documentation if needed.(Required)

Please indicate the length of time you have practiced the religion, belief, or observance preventing you from receiving the COVID-19 vaccine/booster.(Required)

Consent(Required)

By submitting this form, I certify that I have read and agree to the statement below.

By submitting this form, you certify that the information you have provided in connection with this request is accurate and complete as of the date of submission. If any of the information you provided in support of this exemption is false, this may be considered a violation of The Student Code and of your program's professional standards.

You further acknowledge that if your request is approved, you will receive a religious exemption from the COVID-19 vaccine or for the COVID-19 booster for purposes of your clinical or field placement and will be required to comply with any agency requirements for testing, masking, etc. Any costs of testing will be at your own expense. You understand that not all agencies will accept a religious exemption in lieu of full COVID-19 vaccination. UConn is not responsible for placing students who do not meet agency requirements.

Updates to these requirements may be made based on evolving University, state and federal public health guidance.

You understand that by submitting this form, if granted an exemption, your name and vaccination status will be shared to the extent necessary to ensure compliance with health and safety requirements for unvaccinated individuals. You agree to comply with these restrictions and accept the responsibility for compliance with all health and safety requirements.

Also by submitting this form, you understand and assume the risks of non-vaccination. You understand that COVID-19 vaccination is recommended to protect yourself; other UConn students, faculty and staff; and patients/clients and other providers in your agency from COVID-19 and its complications, including serious illness and death. You hereby agree to comply with all safety measures required by your agency as well as any other necessary and reasonable safety measures.

You also acknowledge that you have read the CDC COVID-19 Vaccine Information (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html)

Name

This field is for validation purposes and should be left unchanged.