Employee Vaccination Mandate Exemption Portal
SSN
Re Enter SSN
Email Address
Re Enter Email Address
First Name
Last Name
Employer Name
Employer Email Address
Phone Number
Date exemption denied
Required:
Completed Vaccination Mandate Exemption Form and any supporting documentation you would like the administrative law judge to consider.
Acceptable file types are:
.jpg .png .pdf.
Max size:
4 MB
By selecting this box, I hereby swear or affirm that the information in this request is true and accurate. I understand that providing false or misleading information is grounds for discipline, up to and including termination from employment.
By selecting this box, I hereby swear or affirm that this document was presented to my employer and that upon their denial of my request for exemption they have signed and provided all required information prior to my uploading this document.
Note:
Please allow up to 30 days for a decision to be made.
Law
Work Flow
Poster
Exemption Form
Request for Administrative Review:
To request a review of the denial of your vaccination exemption claim from your employer, please upload a copy of your denied Vaccination Exemption Claim Form and any additional documentation or evidence you would like for the administrative law judge to consider in their review.