REQUEST FOR RELIGIOUS EXEMPTION OF COVID VACCINE Employee Name: Date of Birth (Please Print) Employee Number: Department and Facility: attest that my sincerely held religious beliefs require me to request an exemption from receiving the COVID-19 vaccine. I understand that requesting an accommodation does not guarantee it will be granted if the accommodation creates an undue hardship on FirstHealth or poses a direct threat to the health and safety of others, T understand that requests for accommodation are assessed on a case by case by Employee Signature Date This portion of the form to be completed by the Vice President, Human Resources or designee. Date Received: Exemption Approved: Yes No If no, explanation: Vice President, Human Resources or Designee Date Copy of completed form returned to employee and original maintained in Employee Health file. FirstHealth _ wovsrroreeciovs OF THE CAROLINAS EXEMPTION OFCOVID VACCINE Oe Page 1 of 1