Request for Accommodations for the Wellness Incentive Program Due to Sincerely Held Religious Beliefs

This form should be used when requesting accommodations for the Wellness Incentive Plan due to sincerely held religious beliefs.

Step 1: Review and acknowledge the information below.

Step 2: Submit the completed request form.

To request disability accommodations as the basis for exemption from the flu vaccine, please contact the Deputy Compliance Officer at DeputyComplianceOfficer@MissouriState.edu or by calling 417-836-6755.

Please don't fill out this input box.

This accommodation request is for*

Flu Vaccine

I understand that according to the Missouri Department of Health and Senior Services Bureau of Immunization, the best way to reduce the risk of getting influenza is through immunization.

For more information about associated risks or obtaining the vaccine, refer to the Magers Health and Wellness Center website.

Requestee details

Title

Personal Pronouns

Full Name*

BearPass ID (M Number)*

Contact preference

Preferred method of contact

Phone Number*

University Email*

Briefly summarize the nature of your request, and the reason for making the request.*

Acknowledgement*

I understand that this is a legal representation of my signature.