{"id":36382,"date":"2022-03-08T19:07:06","date_gmt":"2022-03-08T19:07:06","guid":{"rendered":"https:\/\/mitchellhamline.edu\/dean-of-students\/?page_id=36382"},"modified":"2022-03-17T17:57:07","modified_gmt":"2022-03-17T17:57:07","slug":"covid-19-vaccination-exemption-request-form","status":"publish","type":"page","link":"https:\/\/mitchellhamline.edu\/dean-of-students\/covid-19-vaccination-exemption-request-form\/","title":{"rendered":"COVID-19 Vaccination Accommodation Request Form"},"content":{"rendered":"<div class=\"introduction-wrapper\">\n<p>In accordance with the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973 and Title VII of the Civil Rights Act of 1964, and any other applicable state or local law, Mitchell Hamline School of Law will provide reasonable accommodations from its vaccination requirement to qualified students with documented disabilities, other medical reasons that may not qualify as a disability under federal, state, or local law, or a conscientiously or sincerely held religious belief, observance, or practice that conflicts with the COVID-19 Vaccination Policy, unless providing such accommodations creates an undue hardship for the law school. All requests will be reviewed by the Office of the Dean of Students.<\/p>\n<p>Students who believe they may need a vaccine accommodation because of a documented disability, other medical reasons that may not qualify as a disability under federal, state, or local law, or a conscientiously or sincerely held religious belief, observance, or practice that conflicts with the COVID-19 Vaccination Policy should use this form to submit their request. Vaccination accommodation requests will be reviewed by the Office of the Dean of Students.<br \/>\n<strong><br \/>\n<\/strong>All students who receive a COVID-19 vaccine accommodation must still follow all other Mitchell Hamline COVID-19 protocols. If there is a COVID-19 outbreak, students may be required to stay off campus and attend classes remotely.<\/p>\n<p>All medical information provided pursuant to this policy will be treated confidentially.<\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<link rel='stylesheet' id='formidable-css' href='https:\/\/mitchellhamline.edu\/dean-of-students\/wp-content\/plugins\/formidable\/css\/formidableforms58.css?ver=313447' type='text\/css' media='all' \/><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_26_container\" ><form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_covid-19vaccinationexemptionrequestform\" ><div class=\"frm_form_fields \"><fieldset><legend class=\"frm_screen_reader\">COVID-19 Vaccination Exemption Request Form<\/legend><div class=\"frm_fields_container\"><input type=\"hidden\" name=\"frm_action\" value=\"create\" \/><input type=\"hidden\" name=\"form_id\" value=\"26\" \/><input type=\"hidden\" name=\"frm_hide_fields_26\" id=\"frm_hide_fields_26\" value=\"\" \/><input type=\"hidden\" name=\"form_key\" value=\"covid-19vaccinationexemptionrequestform\" \/><input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/><input type=\"hidden\" id=\"frm_submit_entry_26\" name=\"frm_submit_entry_26\" value=\"ea044404d1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/dean-of-students\/wp-json\/wp\/v2\/pages\/36382\" \/><div id=\"frm_field_424_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half frm_first\"><label for=\"field_nwtmn\" id=\"field_nwtmn_label\" class=\"frm_primary_label\">First name<span class=\"frm_required\">*<\/span><\/label><input  type=\"text\" id=\"field_nwtmn\" name=\"item_meta[424]\" value=\"\"  data-reqmsg=\"First name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/><\/div><div id=\"frm_field_425_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\"><label for=\"field_if5c9\" id=\"field_if5c9_label\" class=\"frm_primary_label\">Last name<span class=\"frm_required\">*<\/span><\/label><input  type=\"text\" id=\"field_if5c9\" name=\"item_meta[425]\" value=\"\"  data-reqmsg=\"Last name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/><\/div><div id=\"frm_field_426_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half frm_first\"><label for=\"field_wofrr\" id=\"field_wofrr_label\" class=\"frm_primary_label\">Mitchell Hamline student ID<span class=\"frm_required\">*<\/span><\/label><input  type=\"text\" id=\"field_wofrr\" name=\"item_meta[426]\" value=\"\"  data-reqmsg=\"Mitchell Hamline student ID cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/><\/div><div id=\"frm_field_431_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\"><label for=\"field_crs0q\" id=\"field_crs0q_label\" class=\"frm_primary_label\">Mitchell Hamline email address<span class=\"frm_required\">*<\/span><\/label><input type=\"email\" id=\"field_crs0q\" name=\"item_meta[431]\" value=\"\"  data-reqmsg=\"Mitchell Hamline email address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/><\/div><div id=\"frm_field_432_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\"><div  id=\"field_j3qj_label\" class=\"frm_primary_label\">Program Enrollment<span class=\"frm_required\">*<\/span><\/div><div class=\"frm_opt_container\" aria-labelledby=\"field_j3qj_label\" role=\"group\"><div class=\"frm_checkbox\" id=\"frm_checkbox_432-0\"><label  for=\"field_j3qj-0\"><input type=\"checkbox\" name=\"item_meta[432][]\" id=\"field_j3qj-0\" value=\"Traditional On-Campus\"  data-reqmsg=\"Program Enrollment cannot be blank.\" data-invmsg=\"Program Enrollment is invalid\"   aria-required=\"true\"  \/> Traditional On-Campus<\/label><\/div><div class=\"frm_checkbox\" id=\"frm_checkbox_432-1\"><label  for=\"field_j3qj-1\"><input type=\"checkbox\" name=\"item_meta[432][]\" id=\"field_j3qj-1\" value=\"Blended Learning\"  data-reqmsg=\"Program Enrollment cannot be blank.\" data-invmsg=\"Program Enrollment is invalid\"   \/> Blended Learning<\/label><\/div><\/div><\/div><div id=\"frm_field_427_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\"><div  id=\"field_dqtj4_label\" class=\"frm_primary_label\">Year in law school<span class=\"frm_required\">*<\/span><\/div><div class=\"frm_opt_container\" aria-labelledby=\"field_dqtj4_label\" role=\"radiogroup\" aria-required=\"true\"><div class=\"frm_radio\" id=\"frm_radio_427-0\"><label  for=\"field_dqtj4-0\"><input type=\"radio\" name=\"item_meta[427]\" id=\"field_dqtj4-0\" value=\"1L\" data-reqmsg=\"Year in law school cannot be blank.\" data-invmsg=\"Year in law school is invalid\"   \/> 1L<\/label><\/div><div class=\"frm_radio\" id=\"frm_radio_427-1\"><label  for=\"field_dqtj4-1\"><input type=\"radio\" name=\"item_meta[427]\" id=\"field_dqtj4-1\" value=\"2L\" data-reqmsg=\"Year in law school cannot be blank.\" data-invmsg=\"Year in law school is invalid\"   \/> 2L<\/label><\/div><div class=\"frm_radio\" id=\"frm_radio_427-2\"><label  for=\"field_dqtj4-2\"><input type=\"radio\" name=\"item_meta[427]\" id=\"field_dqtj4-2\" value=\"3L\" data-reqmsg=\"Year in law school cannot be blank.\" data-invmsg=\"Year in law school is invalid\"   \/> 3L<\/label><\/div><div class=\"frm_radio\" id=\"frm_radio_427-3\"><label  for=\"field_dqtj4-3\"><input type=\"radio\" name=\"item_meta[427]\" id=\"field_dqtj4-3\" value=\"4L\" data-reqmsg=\"Year in law school cannot be blank.\" data-invmsg=\"Year in law school is invalid\"   \/> 4L<\/label><\/div><\/div><\/div><div id=\"frm_field_428_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\"><div  id=\"field_vx3wm_label\" class=\"frm_primary_label\">Reason for exemption<span class=\"frm_required\">*<\/span><\/div><div class=\"frm_opt_container\" aria-labelledby=\"field_vx3wm_label\" role=\"group\"><div class=\"frm_checkbox\" id=\"frm_checkbox_428-0\"><label  for=\"field_vx3wm-0\"><input type=\"checkbox\" name=\"item_meta[428][]\" id=\"field_vx3wm-0\" value=\"Disability Related\"  data-reqmsg=\"Reason for exemption cannot be blank.\" data-invmsg=\"Reason for exemption is invalid\"   aria-required=\"true\"  \/> Disability Related<\/label><\/div><div class=\"frm_checkbox\" id=\"frm_checkbox_428-1\"><label  for=\"field_vx3wm-1\"><input type=\"checkbox\" name=\"item_meta[428][]\" id=\"field_vx3wm-1\" value=\"Medical reasons\"  data-reqmsg=\"Reason for exemption cannot be blank.\" data-invmsg=\"Reason for exemption is invalid\"   \/> Medical reasons<\/label><\/div><div class=\"frm_checkbox\" id=\"frm_checkbox_428-2\"><label  for=\"field_vx3wm-2\"><input type=\"checkbox\" name=\"item_meta[428][]\" id=\"field_vx3wm-2\" value=\"Non-medical reasons\"  data-reqmsg=\"Reason for exemption cannot be blank.\" data-invmsg=\"Reason for exemption is invalid\"   \/> Non-medical reasons<\/label><\/div><\/div><div class=\"frm_description\" id=\"frm_desc_field_vx3wm\"><\/h3><p><strong>Disability Related<\/strong><br \/>Students who believe they may need a reasonable accommodation due to a documented disability that conflicts with the COVID-19 Vaccination Policy should submit a request for a disability accommodation. The request also must include sufficient documentation from a licensed medical provider supporting the need for an exemption from the COVID-19 vaccine due to the disability. Additional documentation may be requested if needed.<\/p><p><strong>Medical Reasons<\/strong><br \/>Students who believe they may need a reasonable accommodation from the COVID-19 Vaccination Policy for medical reasons that may not qualify as a disability under federal, state, or local law should submit a request for a medical accommodation. The request must include sufficient documentation from a licensed medical provider supporting the need for an exemption from the COVID-19 vaccine due to the medical condition. Additional documentation may be requested if needed.<\/p>  <p><strong>Non-medical Reasons<\/strong><br \/>Students who believe they may need a reasonable accommodation based on a conscientiously or sincerely held religious belief, observance, or practice that conflicts with the COVID-19 Vaccination Policy should submit a request for a non-medical exemption. The request must explain why vaccination against COVID-19 is contrary to a conscientiously or sincerely held religious belief,  observance, or practice and include a notarized statement signed by the student stating that the student has not been immunized as required because of a conscientiously or sincerely held religious belief, observance, or practice.<\/p><\/div><\/div><div id=\"frm_field_429_container\" class=\"frm_form_field form-field  frm_top_container\"><div  id=\"field_u6ep_label\" class=\"frm_primary_label\">Documentation<span class=\"frm_required\"><\/span><\/div><input type=\"hidden\"  data-invmsg=\"File Upload is invalid\" aria-invalid=\"false\"   name=\"item_meta[429][]\"  value=\"\" data-frmfile=\"429\" \/><div class=\"frm_dropzone frm_multi_upload frm_clearfix\" id=\"file429_dropzone\" role=\"group\"  aria-describedby=\"frm_desc_field_u6ep\"><div class=\"fallback\"><input type=\"file\" name=\"file429[]\" id=\"field_u6ep\" data-frmfile=\"429\" multiple=\"multiple\"  data-invmsg=\"File Upload is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_clearfix \"><\/div><\/div><div class=\"dz-message needsclick\"><svg  viewBox=\"0 0 18 18\" class=\"frmsvg frm-svg-icon\"><path viewBox=\"0 0 18 18\" fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M8.2 4v8a.8.8 0 001.5 0V4l2.1 2.2A.7.7 0 1013 5L9.5 1.7a.7.7 0 00-1.1 0L5.1 5.2a.8.8 0 001 1l2.1-2zm7.6 4.3c.4 0 .7.3.7.7v6.8c0 .4-.3.7-.8.7H2.3a.8.8 0 01-.8-.8V9A.8.8 0 013 9v6h12V9c0-.4.3-.8.8-.8z\"><\/path><\/svg><span class=\"frm_upload_text\"><button type=\"button\" aria-label=\"Documentation. Drop a file here or click to upload. Maximum file size: 22.53MB\">Drop a file here or click to upload<\/button><\/span><span class=\"frm_compact_text\"><button type=\"button\" aria-label=\"Documentation. Choose File. Maximum file size: 22.53MB\">Choose File<\/button><\/span><div class=\"frm_small_text\"><p>Maximum file size: 22.53MB<\/p><\/div><\/div><\/div><div class=\"frm_description\" id=\"frm_desc_field_u6ep\"><p>All vaccination exemption requests must include documentation based on the guidelines above. <\/p><\/div><\/div><div id=\"frm_field_430_container\" class=\"frm_form_field form-field  frm_none_container\"><label for=\"g-recaptcha-response\" id=\"field_qanc1_label\" class=\"frm_primary_label\">reCAPTCHA<span class=\"frm_required\"><\/span><\/label><div  id=\"field_qanc1\" class=\"frm-g-recaptcha\" data-sitekey=\"6Lc60SsUAAAAACBhG8Aftah6ObEfAyK6R_QBSsF1\" data-size=\"invisible\" data-theme=\"light\"><\/div><\/div><input type=\"hidden\" name=\"item_key\" value=\"\" \/><div id=\"frm_field_664_container\"><label for=\"field_5r3ju\" >If you are human, leave this field blank.<\/label><input  id=\"field_5r3ju\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[664]\" value=\"\"  \/><\/div><input name=\"frm_state\" type=\"hidden\" value=\"VQw4KVqGXSb9\/M3liJPiR7ymt1uivi1xEWyr+AI6OOQWCRm0SqqWKYOPPnGCBlsn\" \/><div class=\"frm_submit\"><button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button><\/div><\/div><\/fieldset><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>In accordance with the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973 and Title VII of the Civil Rights Act of 1964, and any other applicable state or local law, Mitchell Hamline School of Law will provide reasonable accommodations from its vaccination requirement to qualified students with documented disabilities, other medical &hellip; <\/p>\n<p><a href=\"https:\/\/mitchellhamline.edu\/dean-of-students\/covid-19-vaccination-exemption-request-form\/\" class=\"more-link\">COVID-19 Vaccination Accommodation Request Form<\/a><\/p>\n","protected":false},"author":12048,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"class_list":{"0":"post-36382","1":"page","2":"type-page","3":"status-publish","5":"entry"},"acf":[],"_links":{"self":[{"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/pages\/36382","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/users\/12048"}],"replies":[{"embeddable":true,"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/comments?post=36382"}],"version-history":[{"count":0,"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/pages\/36382\/revisions"}],"wp:attachment":[{"href":"https:\/\/mitchellhamline.edu\/dean-of-students\/wp-json\/wp\/v2\/media?parent=36382"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}