Fields marked with an asterisk (*) are required Date: 03/24/2022 10:22 AM *Your Last Name: *Your First Name: *Home Address: *City: *State: --AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY *Zip Code: *Home Telephone: *Cellular Telephone: *E-mail Address: *Confirm E-mail Address: *Employer Name: *Employer Address: *Employer Telephone: *Location Where You Worked: 1. *Are you currently employed with the Employer? Yes No 2. *Does your Employer require that you obtain a COVID-19 vaccine? Yes No 3. *Does your Employer offer exemptions from their vaccine mandate? Yes No 4. *Did you submit a vaccine exemption to your Employer? Yes No 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? Yes No 6. Did you apply for an exemption based on medical reasons? (IF NO, SKIP TO QUESTION 7) Yes No a. If you did, did you submit an exemption statement to the Employer? Yes No 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? Yes No c. If you did, did that medical exemption statement state that vaccination was not in your best medical interest? Yes No d. Did the Employer deny the medical exemption? Yes No 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? Yes No 8. Did you apply for an exemption based on religious reasons? (IF NO, SKIP TO QUESTION 9) Yes No a. If you did, did you submit an exemption statement to the Employer? Yes No b. Did the exemption statement indicate that you declined to get vaccinated because of sincerely held religious beliefs? Yes No c. Did the Employer deny the religious exemption? Yes No 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? Yes No 10. Did you apply for an exemption based on COVID-19 immunity? (IF NO, SKIP TO QUESTION 11) Yes No a. If you did, did you submit an exemption statement to the Employer? Yes No b. If you submitted an exemption statement, did you submit competent medical evidence, supporting the exemption request? Yes No c. Did your exemption statement include the results of a valid laboratory test performed on you? Yes No d. Did the Employer deny the COVID-19 immunity exemption? Yes No 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? Yes No 12. Did you apply for an exemption based on periodic ongoing testing? (IF NO, SKIP TO QUESTION 13) Yes No a. If you did, did you submit an exemption statement to the Employer? Yes No b. If you did, did you agree to submit to regular testing for COVID-19 at no cost to you? Yes No c. Did the Employer deny the testing exemption? Yes No 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? Yes No 14. Did you apply for an exemption based on wearing employer-provided personal protection equipment? (IF NO, SKIP TO QUESTION 15) Yes No a. If you did, did you submit an exemption statement to the Employer? Yes No b. If you did, did you agree to wear employer-provided personal protection equipment when in the presence of other employees or other persons? Yes No c. Did the Employer deny the employer-provided personal protective equipment exemption? Yes No PLEASE ATTACH A COPY OF YOUR EXEMPTION STATEMENT AND ANY OTHER PAPERWORK TO THIS COMPLAINT. EMPLOYER ACTIONS 15. *Were you terminated by your Employer for failure to obtain a COVID-19 vaccine? Yes No a. Date of termination: 16. *Was adverse employment action taken against you that was the functional equivalent of termination?* Yes No *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. Please describe the action taken against you if you claim that was the functional equivalent of termination? Characters remaining: PLEASE ATTACH A COPY OF WHATEVER DOCUMENTS YOU MAY HAVE SHOWING THE TERMINATION OR FUNCTIONAL EQUIVALENT OF TERMINATION TAKEN AGAINST YOU. 17. How many employees does the Employer have? less than 100 more than 100 18. If you are submitting this information as a follow-up to a previously filed complaint, please provide the Identification Number previously provided to you (if applicable): File Uploads - Submit Documentation Below Submit documentation below . Upload 1 Upload 2 Upload 3 Upload 4 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. *You must click the "I Agree" button before you click on the "Submit" button. I Agree Validate Form (Disabled) Check Acceptance above
