Health Surveillance Exemption Form
Use this form to request a Health Surveillance Exemption Form by providing requester details, exemption information, reason, and any supporting context.
Requester Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employment or Organization Details
Organization / Company Name
*
Department or Team
Job Title or Role
Exemption Request Details
Surveillance Program or Requirement Name
*
Exemption Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exemption End Date or Expected End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exemption Type
*
Temporary medical exemption
Ongoing condition-related exemption
Travel-related exemption
Religious or belief-based exemption
Workplace accommodation exemption
Other
If Other, specify
Reason and Supporting Information
Reason for Exemption
*
Supporting Notes or Context
Supporting Documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Health Surveillance Exemption Form
Should be Empty: