San Jose-Evergreen Community College District Vaccine Exemption Request Intake Form

San Jose-Evergreen Community College District
Vaccine Exemption Request
Intake Form

Name(Required)
If you do not use your work email please note email communications from our system may get caught in your spam folder.
Address(Required)
Supervisor Name(Required)
Are you faculty that teaches classes?(Required)
I am requesting a workplace vaccine exemption:(Required)
Consent(Required)
Electronic Signature(Required)

If you have any questions about this form please email: SJECCD@shawhrconsulting.com