Vaccination Policy - Template, Sample Form to Complete Pro · US-law
✓ Valid in United States · drafted to comply with local law
Create your Vaccination Policy - Template, Sample Form to Complete for use in United States. Answer a few plain-English questions and the document fills in automatically as you go — then download it in Word and PDF, ready to sign or share. This version has been professionally rewritten to comply with local law.
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WORKPLACE VACCINATION POLICY
________
State of ________
RECITALS:
A. This Workplace Vaccination Policy (the “Policy”) is adopted and made effective as of ________ by ________, a ________ with its principal place of business at ________ (the “Employer” or “Company”).
B. This Policy sets forth the terms, conditions, procedures, and expectations regarding vaccinations applicable to the employees of the Employer (each, an “Employee”).
C. The purpose of this Policy is to reduce the transmission of communicable disease in the workplace, to protect the health and safety of Employees, visitors, and the community, and to maintain a safe and healthful workplace consistent with the Employer’s general duty obligations under the Occupational Safety and Health Act of 1970, 29 U.S.C. § 654(a)(1).
By signing this document, an Employee acknowledges receipt of and agreement to comply with the following terms:
§ I. SCOPE AND APPLICATION.
1. This Policy applies to all Employees of the Employer who are required to maintain current vaccinations to protect the health and safety of personnel, visitors, and the community, except as otherwise provided herein.
2. This Policy does not apply to the following categories of Employees:
________
3. The following individual is designated as the authorized administrator responsible for implementing, interpreting, and applying this Policy in the workplace: ________, holding the position of ________ (the “Policy Administrator”).
§ II. VACCINATION REQUIREMENTS.
4. Subject to the exemptions and accommodations set forth in § III, the following vaccinations are required for all covered Employees, to the extent recommended by the Employee’s licensed healthcare provider and applicable public health authorities:
a. Seasonal influenza (flu);
b. Vaccines for pandemic-causing viruses, as recommended by public health authorities;
c. Tetanus, diphtheria, and pertussis (Tdap);
d. Meningococcal (meningitis);
e. Measles, mumps, and rubella (MMR);
f. Varicella (chickenpox);
g. Hepatitis A;
h. Hepatitis B;
i. Pneumococcal; and
j. Such additional vaccinations as may be required by applicable law or recommended by the Centers for Disease Control and Prevention: ________.
5. All covered Employees must adhere to the vaccination schedule approved by their licensed healthcare provider.
6. The Employer shall provide paid time off, as required by applicable law and Company policy, to enable Employees to obtain the required vaccinations.
7. Each covered Employee must certify that they have received the required vaccinations and must maintain documentation of such certification, which the Employee shall provide promptly upon the Employer’s reasonable request. All such medical information shall be maintained as a confidential medical record, stored separately from the Employee’s personnel file, in accordance with applicable law.
8. Newly hired Employees must present proof of the required vaccinations within ________ days prior to their start date.
9. Newly hired Employees engaged outside the months when certain seasonal vaccines are available will be notified of this Policy and will be expected to comply in the next applicable season.
§ III. EXEMPTIONS AND REASONABLE ACCOMMODATIONS.
10. Consistent with the Americans with Disabilities Act and Title VII of the Civil Rights Act of 1964, an Employee may request an exemption from one or more vaccination requirements on the following grounds:
a. A medical contraindication or disability, including a severe (life-threatening) allergy to a component of the vaccine, supported by documentation from a licensed healthcare provider; or
b. A sincerely held religious belief, practice, or observance that conflicts with the vaccination requirement; or
c. Such additional grounds as may be required to be recognized under applicable federal, state, or local law.
11. Any Employee who qualifies for a medical exemption and nonetheless wishes to be vaccinated should consult their primary healthcare provider.
12. To request an exemption, an Employee must submit a written request to the Policy Administrator, together with any applicable supporting documentation. The Employer will engage in a good-faith interactive process and will review the request and provide a reasonable accommodation unless doing so would impose an undue hardship on the Employer or pose a direct threat to the health or safety of the workplace.
13. To reduce the risk of transmission, an Employee granted an exemption or accommodation under this Section may, where consistent with applicable law and the interactive process, be required to comply with one or more of the following reasonable accommodation measures:
a. Wearing a face covering while working on the Employer’s premises, except when outdoors;
b. Working remotely, where feasible;
c. Avoiding common areas and group gatherings on Company property; and
d. Providing negative diagnostic test results upon reasonable request.
§ IV. NONCOMPLIANCE.
15. An Employee who fails to provide documentation of vaccination or an approved exemption will be deemed noncompliant with this Policy.
16. If an Employee fails to comply within the time frames specified herein, the Employee will receive a written warning from their supervisor or the Policy Administrator. The Employee shall have ________ days from issuance of the written warning to come into compliance, whether through vaccination, proof of an approved medical exemption, or an approved religious accommodation.
17. If the Employee remains noncompliant after ________ days following issuance of the written warning, the Employer may suspend the Employee on the following terms:
________
18. If, following the suspension period, the Employee remains noncompliant with this Policy, the Employer may terminate the Employee’s employment, subject to applicable law. Nothing in this Section limits the Employer’s obligation to provide reasonable accommodations as required under § III.
§ V. GENERAL PROVISIONS.
19. Amendment. The Employer reserves the right to amend, modify, suspend, or terminate this Policy at any time, in its sole discretion, as may be necessary to comply with applicable laws, regulations, or public health guidance. Employees will be notified of any material changes to this Policy.
20. Severability. If any provision of this Policy is found to be invalid, illegal, or unenforceable, the remaining provisions shall continue in full force and effect, and this Policy shall be construed as if such invalid provision had never been contained herein.
21. Compliance with Law. This Policy shall be interpreted and administered in accordance with all applicable federal, state, and local laws, and shall be construed to conform to such laws wherever a conflict may arise.
22. No Waiver. The Employer’s failure to enforce any provision of this Policy shall not constitute a waiver of its right to enforce that or any other provision in the future.
23. Confidentiality. All medical and exemption-related information collected pursuant to this Policy shall be treated as confidential and maintained in accordance with applicable law.
§ VI. ACKNOWLEDGMENT AND AT-WILL EMPLOYMENT.
24. By signing below, the Employee acknowledges and confirms that they have read, understood, and agree to comply with all provisions of this Policy.
25. The Employee acknowledges that this Policy is a guideline and does not create, and shall not be construed to create, any contract of employment or any contractual obligation between the parties, nor does it alter the at-will nature of employment where applicable. Any existing written employment agreement between the Employer and the Employee shall control to the extent of any conflict.
§ VII. GOVERNING LAW AND VENUE.
26. This Policy shall be governed by and construed in accordance with the laws of the State of ________, without regard to its conflict-of-laws principles. The parties consent to the exclusive jurisdiction and venue of the state and federal courts located in ________ County, State of ________, and agree that this choice of law, venue, and jurisdiction provision is mandatory and not permissive.
EXECUTION:
IN WITNESS WHEREOF, the undersigned Employee acknowledges receipt and understanding of this Policy as of the date set forth below:
_________________________________
Employee Signature
_________________________________
Employee Name: ________
_________________
Date: ________
Acknowledged on behalf of the Employer:
_________________________________
Authorized Representative Signature
_________________________________
Name: ________
Title: ________
_________________
Date: ________
Fields you complete are inserted into the document live. This template is general guidance only — not legal advice.