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Date: 01/22/2022 10:41 PM
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MEDICAL EXEMPTIONS

5.Did your Employer offer an exemption based on medical reasons, including, but not limited to, an employee's pregnancy or attempted pregnancy?
6.Did you apply for an exemption based on medical reasons? (IF NO, SKIP TO QUESTION 7)
 a.If you did, did you submit an exemption statement to the Employer?
 b.If you did, was that medical exemption dated and signed by a physician, physician assistant or advance practice registered nurse who had examined you?
 c.If you did, did that medical exemption statement state that vaccination was not in your best medical interest?
 d.Did the Employer deny the medical exemption?
PLEASE ATTACH A COPY OF YOUR EXEMPTION STATEMENT AND ANY OTHER PAPERWORK TO THIS COMPLAINT. IF AN EXEMPTION BASED ON MEDICAL REASONS WAS THE SOLE EXEMPTION CLAIMED, GO TO QUESTION 15.

RELIGIOUS EXEMPTIONS

7.Did your Employer offer an exemption based on religious reasons?
8.Did you apply for an exemption based on religious reasons? (IF NO, SKIP TO QUESTION 9)
 a.If you did, did you submit an exemption statement to the Employer?
 b.Did the exemption statement indicate that you declined to get vaccinated because of sincerely held religious beliefs?
 c.Did the Employer deny the religious exemption?
PLEASE ATTACH A COPY OF YOUR EXEMPTION STATEMENT AND ANY OTHER PAPERWORK TO THIS COMPLAINT. IF AN EXEMPTION BASED ON RELIGIOUS REASONS WAS THE SOLE EXEMPTION CLAIMED, GO TO QUESTION 15.

COVID-19 IMMUNITY EXEMPTIONS

9.Did your Employer offer an exemption based on COVID-19 immunity?
10.Did you apply for an exemption based on COVID-19 immunity? (IF NO, SKIP TO QUESTION 11)
 a.If you did, did you submit an exemption statement to the Employer?
 b.If you submitted an exemption statement, did you submit competent medical evidence, supporting the exemption request?
 c.Did your exemption statement include the results of a valid laboratory test performed on you?
 d.Did the Employer deny the COVID-19 immunity exemption?
PLEASE ATTACH A COPY OF YOUR EXEMPTION STATEMENT AND ANY OTHER PAPERWORK TO THIS COMPLAINT. IF AN EXEMPTION BASED ON COVID-19 IMMUNITY REASONS WAS THE SOLE EXEMPTION CLAIMED, GO TO QUESTION 15.

PERIODIC ONGOING TESTING EXEMPTIONS

11.Did your Employer offer an exemption based on periodic ongoing testing?
12.Did you apply for an exemption based on periodic ongoing testing? (IF NO, SKIP TO QUESTION 13)
 a.If you did, did you submit an exemption statement to the Employer?
 b.If you did, did you agree to submit to regular testing for COVID-19 at no cost to you?
 c.Did the Employer deny the testing exemption?
PLEASE ATTACH A COPY OF YOUR EXEMPTION STATEMENT AND ANY OTHER PAPERWORK TO THIS COMPLAINT. IF AN EXEMPTION BASED ON TESTING WAS THE SOLE EXEMPTION CLAIMED, GO TO QUESTION 15.

EMPLOYER-PROVIDED PPE EXEMPTIONS

13.Did your Employer offer an exemption based on wearing employer-provided personal protective equipment?
14.Did you apply for an exemption based on wearing employer-provided personal protection equipment? (IF NO, SKIP TO QUESTION 15)
 a.If you did, did you submit an exemption statement to the Employer?
 b.If you did, did you agree to wear employer-provided personal protection equipment when in the presence of other employees or other persons?
 c.Did the Employer deny the employer-provided personal protective equipment exemption?
PLEASE ATTACH A COPY OF YOUR EXEMPTION STATEMENT AND ANY OTHER PAPERWORK TO THIS COMPLAINT.

EMPLOYER ACTIONS

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*The employer, through its actions, made working conditions so difficult or intolerable that a reasonable person in the employee's position would feel compelled to resign.
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PLEASE ATTACH A COPY OF WHATEVER DOCUMENTS YOU MAY HAVE SHOWING THE TERMINATION OR FUNCTIONAL EQUIVALENT OF TERMINATION TAKEN AGAINST YOU.

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I declare that the statements made in connection with this complaint are true and correct to the best of my knowledge and belief. I understand the information contained herein is subject to verification and agree to provide such documentation or verification as required. I understand that if I fail to provide any such documentation or respond to requests for verification, this complaint may be denied.

I also understand that the Office of the Attorney General of Florida does not give legal advice, and that the Office of the Attorney General of Florida cannot take legal action for me individually. Further, I understand that the information submitted with this complaint may be provided to the Employer named in the complaint and may also be subject to public inspection pursuant to Chapter 119, Florida Statutes.

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