* = Required Information

I am requesting a medical exemption from Faithful Home Care Solutions LLC’s mandatory vaccination policy for my health condition. My current health condition prevents me from getting the COVID-19 vaccination due to possible complications and side effects.

I verify that the information I am submitting to substantiate my request for exemption from Faithful Home Care Solutions LLC’s vaccination policy is true and accurate to the best of my knowledge. I understand that any falsified information can lead to disciplinary action, up to and including termination.

I further understand that Faithful Home Care Solutions LLC is not required to provide this exemption accommodation if doing so would pose a direct threat to myself or others in the workplace or would create an undue hardship for Faithful Home Care Solutions LLC.

Attach herewith is/are the document/s proving my medical condition is true and my request for exemption is valid.