Va Religious Exemption Form. Rac will assign log number below for record keeping purposes. Received the seasonal influenza vaccine this flu season.
West Virginia Tax Exempt
Number __________________________________ the administration of immunizing agents conflicts with the above named student's/my religious tenets or. Received the seasonal influenza vaccine this flu season. This form should be retained separately from the employee's official personnel folder. Please read the descriptions below to learn the criteria to request a medical or religious exception. The student or his parent or guardian submits a notarized certificate of religious exemption (form cre 1), to the admitting official of the school to which the student is seeking admission. I have read and fully understand the information on this form and have been given the opportunity to have my questions answered. Form cre 1 is an affidavit stating that the administration of immunizing agents conflicts with the student's religious tenets or practices. Check one statement below and complete and sign the last section of this form prior to submission to employee occupational health: Web commonwealth of virginia certificate of religious exemption name ____________________________________ birth date _______________________ student i.d. You may select medical exception, religious exception, or select both if you meet the criteria for both a medical and religious exception.
Web employees should provide this form to the rac. Regarding religious requests, approvals will be annotated on va form 10230b and written notice of the approval This form should be retained separately from the employee's official personnel folder. Fully vaccinated (required documentation attached): Please read the descriptions below to learn the criteria to request a medical or religious exception. Number __________________________________ the administration of immunizing agents conflicts with the above named student's/my religious tenets or. Web regarding disability requests, approvals will be annotated on both the va form 10230a and va form 0857f, accommodation request determination, in accordance with va handbook 5975.1. Trainee, resident, intern, fee basis, or researcher) please indicate: Received the seasonal influenza vaccine this flu season. Web commonwealth of virginia certificate of religious exemption name ____________________________________ birth date _______________________ student i.d. I have read and fully understand the information on this form and have been given the opportunity to have my questions answered.
