How to Fill Out and Submit a COVID-19 Vaccination Declination Form

A COVID-19 vaccination declination form is the document you give your employer to request an exemption from a workplace vaccine requirement, almost always on medical or religious grounds. To fill it out well, identify which basis applies to you, write a specific explanation of the condition or belief that prevents you from being vaccinated, attach the documentation your employer’s policy requires, and submit it through the exact channel HR specifies while keeping your own copy of everything. The form is not standardized, but the legal framework behind it — the Americans with Disabilities Act for medical requests and Title VII of the Civil Rights Act for religious ones — is the same for every covered employer.

Whether You Still Need One

The federal picture has changed. Executive Order 14043, which required COVID-19 vaccination as a condition of federal employment, has been repealed, and a 2025 Office of Personnel Management memorandum now prohibits federal agencies from using vaccine status, prior noncompliance, or past exemption requests in employment decisions.¹ The CMS interim final rule that required vaccination for staff at Medicare- and Medicaid-certified healthcare facilities has expired.²

Private employers still set their own vaccination policies, and some hospitals, long-term care facilities, and healthcare systems continue to require the vaccine as a condition of employment. If your workplace has such a policy, the declination form is how you formally ask to be excused from it. The protections described below apply either way.

What the Form Asks You to Provide

Because employers write these forms themselves, formats vary, but the core content is consistent. You will supply your full legal name, department, employee ID, and the date of the request. You will then identify the basis for your exemption — medical or religious — and provide a written explanation. Some forms include a separate category for pregnancy-related requests, which are handled under similar accommodation frameworks.

Read your employer’s vaccination policy before you start writing. The policy usually spells out what documentation is required, where to send the form, the review timeline, and the consequences of remaining unvaccinated after a denial. The form itself is short; the strength of your request lives in the written explanation and the documents you attach.

Filling It Out for a Medical Exemption

Medical requests are governed by the ADA. Under 42 U.S.C. § 12112, an employer cannot discriminate against a qualified individual on the basis of disability and must provide reasonable accommodations for known physical or mental limitations unless doing so would impose an undue hardship on the business.³ If a medical condition makes the vaccine dangerous for you, the employer must explore alternatives before denying the request or ending your employment.

Your explanation should be backed by documentation from a licensed healthcare provider. A note saying you “prefer not to be vaccinated” will not carry the request. The provider’s statement should identify the specific condition or allergy that contraindicates the vaccine and explain why the clinical risk is significant. The employer needs enough information to confirm that a real medical barrier exists.

Employers reviewing medical exemptions apply a direct threat analysis. EEOC guidance says that if an unvaccinated employee would pose a “significant risk of substantial harm” to others in the workplace, the employer can require vaccination, but only after determining that no reasonable accommodation can reduce that risk.⁴ That analysis looks very different for a desk worker than for a nurse in an ICU, and your form is stronger if it acknowledges your role and points toward accommodations that fit it.

Filling It Out for a Religious Exemption

Religious requests fall under Title VII, which defines “religion” broadly to include “all aspects of religious observance and practice, as well as belief,” and requires reasonable accommodation absent undue hardship.⁵ The belief does not have to come from an organized religion; it can be new, uncommon, or held by only a small number of people, as long as it occupies a place in your life comparable to traditional religious faith.⁶

Write the statement in your own words and be specific about the belief that conflicts with receiving the vaccine. The EEOC has been clear that the belief must be genuinely religious in nature. Moral or ethical convictions about right and wrong can qualify, but political opinions, general vaccine skepticism, or personal preferences do not.⁶ If the employer has a good-faith doubt about sincerity and asks follow-up questions, cooperate. Refusing to answer reasonable inquiries can cost you the accommodation.

You do not need a letter from a clergy member, though one can help. Verification can come from anyone aware of your religious practice, including a fellow congregant or family member, or from your own detailed first-hand account. A statement is more persuasive when it is specific and consistent with the rest of your life. If you write that your faith forbids putting certain substances in your body, being able to point to a pattern of similar decisions strengthens the claim.

Submitting the Form

Follow the submission method in the policy exactly. Most organizations require the form to go through an HR information system or directly to a compliance officer. If you are mailing physical documents, use certified mail so you have proof of delivery. Either way, keep your own copy of the form, your written statement, and any supporting letters.

Ask for written confirmation that your submission was received. If the system does not generate a receipt automatically, send a short follow-up email to your HR contact noting the date and method of submission. A paper trail protects you if a dispute later arises about whether or when you filed.

Review timelines vary. Some employers process requests within two weeks; larger organizations may take longer. Silence is not approval. If you have not heard anything in a reasonable time, follow up in writing.

What Happens After You Submit

The EEOC expects the employer to start what it calls an “informal, interactive process” to discuss your request and explore possible accommodations.⁷ This is a conversation, not a one-sided verdict. The employer may ask clarifying questions or propose alternatives you had not considered. Common accommodations for unvaccinated employees include wearing a mask, working at a distance from coworkers, a modified schedule, periodic COVID-19 testing, teleworking, or reassignment to a different role.⁴

Your participation matters. If the employer requests reasonable documentation and you refuse to provide it, you forfeit the accommodation.⁷ An employer that ignores your request or refuses to engage in the process can face liability for failing to accommodate.

The Undue Hardship Standard

An employer can deny an accommodation that would cause undue hardship. For medical requests under the ADA, that means “significant difficulty or expense” in relation to the employer’s operations.³

For religious requests under Title VII, the standard changed in 2023. In Groff v. DeJoy, the Supreme Court rejected the old rule that any cost more than trivial was enough to deny a religious accommodation. The Court held that undue hardship requires the employer to show that the accommodation would result in “substantial increased costs in relation to the conduct of its particular business,” considering factors like the specific accommodation requested, its practical impact, and the size and operating costs of the employer.⁸ Religious accommodation requests carry more legal weight than they did before that decision.

Privacy of the Records You Submit

Medical information you submit with the form is protected under the ADA’s confidentiality rules. Under 42 U.S.C. § 12112(d), an employer must keep medical records on separate forms and in separate files from your general personnel records and treat them as confidential.³ A supervisor can be told about necessary restrictions or accommodations, such as a remote-work schedule, but not the underlying medical details. First aid and safety personnel may be informed if a disability might require emergency treatment. If you find that details of your exemption were shared with coworkers or that medical documentation was placed in your general personnel file, that is a potential violation worth raising with HR or an attorney.

If Your Request Is Denied

A denial is not automatically the end. Start with any internal appeal the employer offers; many vaccination policies include a formal appeals procedure. Document the original denial, your appeal, and every HR communication along the way. If you remain unvaccinated past the deadline after a final denial, you may face discipline up to termination depending on the policy.

If internal options fail and you believe the denial was discriminatory, you can file a charge with the EEOC. The general deadline is 180 calendar days from the date the discrimination occurred, extended to 300 calendar days if your state or locality has an agency that enforces a similar anti-discrimination law, which most do.⁹ Federal employees follow a different track and generally must contact their agency’s EEO counselor within 45 days.

One detail matters more than any other here: pursuing an internal grievance, union complaint, or mediation does not pause the EEOC clock. The deadline runs from the date of the discriminatory action regardless of whether you are still working through your employer’s appeal.⁹ If there is any chance you will need to file, contact the EEOC before the internal process concludes.

1
Office of Personnel Management. Prohibition of Use of Vaccine Status Memorandum
2
Centers for Medicare & Medicaid Services. Interim Final Rule – COVID-19 Vaccine Immunization Requirements
3
Office of the Law Revision Counsel. 42 USC 12112 – Discrimination
4
U.S. Equal Employment Opportunity Commission. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws
5
Office of the Law Revision Counsel. 42 USC 2000e – Definitions
6
U.S. Equal Employment Opportunity Commission. Section 12 – Religious Discrimination
7
U.S. Equal Employment Opportunity Commission. Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the ADA
8
Supreme Court of the United States. Groff v. DeJoy, 600 U.S. ___ (2023)
9
U.S. Equal Employment Opportunity Commission. Time Limits for Filing a Charge