Vaccine Accommodation Request Form

If you are requesting an exception to the Company’s mandatory vaccination policy due to your (1) disability or medical condition, or (2) sincerely held religious belief, practice or observance, please complete this form. Accommodations will be considered on a case-by-case basis and may only be approved through the formal Human Resources/Legal process.

Crewmember First Name

Crewmember Last Name

Crewmember Email

Preferred Phone Number

Production Title

Select

New Production Title

If you selected "Unknown" please type your production or segment name here

Today's Date

Is the Accommodation you are requesting medical or religious?

Select

Is your limitation that prevents you from receiving the vaccine permanent or temporary?

Permanent

Temporary

Please explain the nature of limitations resulting from your medical condition

Please do not disclose the underlying condition or genetic information, but please explain how this may prevent you receiving a COVID-19 vaccine.

Possible Vaccine Date

If your condition is temporary, date you may be eligible to receive the vaccine.

Religious Accommodation

If you are unable to receive a COVID-19 vaccination due to a sincerely held religious belief, practice or observance, please explain the nature of your religious belief, practice or observance and how it prevents you from receiving a COVID-19 vaccination. If necessary to evaluate your accommodation request, the Company may ask to discuss the nature of your religious belief, practice or observance and accommodation request with your religion's spiritual leader (if applicable) or another third party who is aware of your religious belief, practice, or observance.

File Upload

Please attach documentation from your medical provider confirming the existence of a disability or medical condition, the duration and resulting limitations, and providing information about how those limitations prevent you from receiving the COVID-19 vaccination. (Please do not disclose the underlying condition or any genetic information.) The Company may ask to discuss your request with your doctor if the documentation provided is not sufficient to evaluate your accommodation request.

Drag and drop files here or

Role

Union?

Union name (if applicable)

Work location

Verification

I verify that the above information is true and accurate and I understand that any misrepresentation may result in disciplinary action, including termination of employment.

Send me a copy of my responses

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