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 COVID-19 vaccine, please contact the Deputy Compliance Officer at DeputyComplianceOfficer@MissouriState.edu or by calling 417-836-6755.

This accommodation request is for*
Understanding the requirements and information
Missouri Department of Health and Senior Services Novel Coronavirus Fact Sheet*
Acknowledgement*
For more information about associated risks or obtaining the vaccine, refer to the Magers Health and Wellness Center website.
Requestee details
Contact preference
Acknowledgement*