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

For use by: New Hire/Rehire Candidate, Medxcel Associate, Community Health Ministry Associate, or Licensed Independent Providers Only

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 requesting a General Influenza exemption, please complete this entire form.

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.

Illinois based associates may not select the General Exemption option due to state law requirements.

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, Medxcel Associates, 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.

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.

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

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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

Anticipated Start Date

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Vaccine Exemption Requested

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Influenza General Exemption

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Exemption Type

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General Exemption

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I agree and understand that if approved for a general exemption I will comply with all infection
prevention and patient safety precautions as required, including donning and doffing of required PPE, other
mask requirements, and any additional requirements as determined for the duration of the accommodation.

If approved for a general exemption for influenza, I attest I will wear a mask during the influenza season from November 10th through March 31st to further mitigate the risk of transmission.

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This form is only for New Hire/Rehire Candidates, Medxcel Associates, Community Health Ministry Associates, or Licensed Independent Providers ONLY.

Current Ascension associates, please use ServiceNow.

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