This sample form was developed in connection with CAPLAW’s Vaccines and the COVID-19 Pandemic series of conversations. The template allows employees to request an exemption from an employee vaccination mandate and provide corroborating information and documentation. It also contains some recordkeeping questions that a CAA might use to standardize and document its process of providing reasonable accommodations. CAPLAW recommends adapting this form to meet the needs of your agency in consultation with local counsel in your state.