City of Long Beach
Vaccine Exemption Intake Form for a Religious Belief
Intake Form

I am a new hire at the City of Long Beach

YES

As of November 22, 2022, existing City of Long Beach employees are not required to submit a vaccine exemption or appeal a denial of an exemption request. For any questions, please contact cityoflongbeachhr-rtw@longbeach.gov.

Name(Required)

First Last

Job Title(Required)

Department(Required)

Email(Required)

Please check your spam folder if you are providing a personal email address to ensure that you receive email communications from our system.

Phone(Required)

I am requesting a workplace vaccine exemption:(Required)

I have a strongly held religious belief, religious practice or religious observance that does not allow me to be administered vaccines, including the COVID-19 vaccine.

I am medically unable to be administered a COVID-19 vaccine because of a personal medical condition.

Consent(Required)

I understand, submitting this form is not a guarantee of approval. I understand the City of Long Beach will require additional verification which I will be notified of following this submission. Following my submission of verification, the City will consider requests and balance how to support employees, while not reducing the quality or volume of City services.

Electronically signed:(Required)

First Last

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City of Long Beach Vaccine Exemption Religious Belief or Medical Reasons Intake Form

City of Long Beach
Vaccine Exemption Intake Form for a Religious Belief
Intake Form

NPELRA Pre-2023 National ATC Conference Workshop

NPELRA 2023 National Conference

Shaw HR Consulting ADA Compliance Boot Camp 2023

City of Long Beach Vaccine Exemption Religious Belief or Medical Reasons Intake Form

City of Long Beach Vaccine Exemption Intake Form for a Religious Belief Intake Form

City of Long Beach
Vaccine Exemption Intake Form for a Religious Belief
Intake Form