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Required format:

New Hire/Rehire Candidate, Medxcel Associate, Community Health Ministry Associate, or Licensed Independent Provider Vaccine Exemption Request Form

For use by: New Hire/Rehire Candidates, Medxcel Associates, Community Health Ministry Associates, or Licensed Independent Providers

In alignment with our values and for the safety of our patients and workforce, some vaccines are required as a condition of employment in a healthcare organization.

If you are requesting exemption for multiple vaccines, please fill out a separate form for EACH vaccine.

For medical exemptions, associates must submit a note from your provider with the following information to support a medical exemption request:

Information specifying which authorized or licensed vaccine is clinically contraindicated;
Information specifying the recognized clinical reasons for the contraindication;
A statement recommending that the individual be exempted from the vaccination requirement based on the medical contraindications.
Signature and date from a licensed practitioner acting in accordance with his or her scope of practice and all applicable law, who cannot be the individual requesting the exemption.
To be completed by individual requesting exemption (ALL fields must be completed).

For approved influenza exemptions, In order to further mitigate the risk of transmission of influenza, all associates granted an exemption and who work in a clinical setting, will be required to wear a mask during the flu season from November 10th to March 31st in accordance with Ascension procedures and any applicable Federal, State, or Local laws. For general exemption requests please click here.

Completion and submission of the exemption form does not guarantee an exemption. Each request is considered on a case by case basis. New Hire/Rehire candidates, Community Health Ministry Associates, and Licensed Independent Providers will be notified of exemption determinations via email.

Submitting a vaccine exemption request may potentially delay a candidate's start date.

Serologic evidence of immunity to Measles, Mumps, and Rubella (MMR); Tetanus, Diphtheria, and Pertussis (TDaP); and Varicella vaccines are required for all Healthcare Workers (HCWs) who work directly with patients or handle material that could spread infection.
Serological evidence of immunity to Meningococcal Vaccine is required for microbiologists who are routinely exposed to Neisseria meningitidis
Candidate exemption requests need to be completed in their entirety. Failure to complete may result in delays in candidate start dates. Incomplete submissions will not be processed.
Candidates will be contacted via email regarding the status of the exemption request.
If the exemption is denied, candidates will be requested to receive the required dose of the vaccine to be cleared to start work.
Candidates who do not receive an approved medical or religious exemption for a required vaccine and still choose to not receive the required vaccine will not be permitted to begin employment with Ascension in alignment with Ascension's Vaccine Policy.
If you receive an approved exemption, you will then be engaged in the accommodation process. There will be additional and ongoing infection prevention requirements you must follow when onsite. These requirements will be communicated to you and your direct supervisor in a follow-up communication.

For Medical or Religious exemptions please continue completion of this form.

Are you a TouchPoint candidate?

* must provide value

Yes No

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Are you a volunteer candidate?

* must provide value

Yes No

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Are you a New Hire/Rehire Candidate, Medxcel Associate, Community Health Ministry Associate, or Licensed Independent Provider?

* must provide value

Yes No

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Are you an Alabama associate?

* must provide value

Yes

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Ascension no longer requires the COVID-19 vaccination as a condition of employment. Ascension continues to strongly recommend vaccination as a safe and effective means of preventing serious illness or death from COVID-19.

If you are requesting an exemption to other vaccines required for employment, please proceed and complete the RedCap New Hire/Rehire Candidate, Medxcel Associate, Community Health Ministry, or Licensed Independent Provider survey.

Are you a Florida associate?

* must provide value

Yes

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Are you a Licensed Independent Provider?
(Medical Staff: Licensed Independent Provider, Provider Service Agreement, Affiliate)

Yes No

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submission_date

M-D-Y H:M

Name of Individual Requesting Exemption	First Name:	Last Name:
Location (hospital name, clinic location, Ascension Nurse Travel Program, etc.)
Job Title
State of Residence
Date of Birth
Email Address
Telephone Number

Will you an independent provider who strictly provides telemedicine services to any Ascension facility and does not intend to provide patient care outside of telemedicine consultation?

Yes No

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Hiring Manager Name
If unknown, please refer to your offer letter.

* must provide value

Recruiter/Candidate Experience Coordinator Name

* must provide value

Anticipated Start Date

* must provide value

M-D-Y

Vaccine Exemption Requested

If you are requesting exemption for multiple vaccines, please fill out the form for each vaccine.

* must provide value

Influenza Vaccine - All Associates

Measles, Mumps, Rubella (MMR)

Tetanus, Diphtheria, Pertussis (TDAP)

Varicella

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Exemption Type

* must provide value

Religious Exemption

Medical Exemption

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This form is only for New Hire Candidates, Community Health Ministry Associates, and Licensed Independent Providers ONLY.

Please reach out to your Recruiter/Human Resources Representative for information on submitting an exemption with TouchPoint.

You must complete this form to continue

Please reach out to your local Volunteer Office.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.