This can be attached to your application for Religious Exemption or, ideally, presented beforehand.

SUBJECT: Information regarding your requirement that I submit to Covid-19 vaccination as a condition of my continued employment.

PART 1: Verify Safety and Efficacy of Vaccine. 

A. Please provide verifiable evidence that: The injection is safe.  

FACT: Based on the number of reports received by the federal government’s VAERS system, which receives reports of only between 1% and 10% of all adverse vaccine events, Covid 19 vaccines are the most dangerous ever devised, with over 818,000 adverse events and over 17,100 deaths reported since December of 2020 (as of 10/23/21).

B. Please provide verifiable evidence that: The injection will cause me no short or long-term health problems, up to and including death. 

FACT: VAERS data show that the total reported vaccine deaths in the first quarter of 2021 represents a 12,000% to 25,000% increase in vaccine deaths, year-over-year. The disastrous 1976 Swine Flu vaccine was pulled off the market as unsafe after a mere 53 reported deaths among 55 million recipients of the vaccine.

C. Please provide verifiable evidence that: My health is endangered by my failure to submit to the injections you require in order for me to keep my job. 

FACT: CDC data shows that the Covid vaccines do not treat or prevent infection with SARS-CoV-2 or COVID-19, nor do they prevent transmission. The case fatality rate from Covid 19 itself, using government case and death numbers, does not exceed .003% for the U.S. population under 70 years of age. For most Americans Covid 19 is no more dangerous than the seasonal flu.

D. Please provide verifiable evidence that: My failure to receive this vaccine will endanger my co-workers, our clients or customers, or anyone else. 

FACT: At the time of the EUA, the FDA stated that the “data was not available to make a determination about how long the vaccine will provide protection, nor is there evidence that the vaccine prevents transmission of SARS-CoV-2 [i.e., the virus that causes COVID-19] from person to person.” According to official sources, there is NO EVIDENCE that the Covid 19 vaccine prevents transmission from person to person. According to a recent Harvard study, 5 months after receiving the vaccine, your protection is reduced to 23%. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8481107/)

PART 2: Request for Further Information

I also have some questions for you as the person requiring that I take the Covid 19 vaccine in order to keep my job. I am requesting that you review these questions, provide the requested information, and sign this letter. 

Does my employee health insurance plan provide complete coverage should I experience an adverse event, or even death?

Yes ____ No ____

As your employee, does my life insurance policy provide any coverage if I die from having received an EUA Covid-19 injection?

Yes ____ No ____

As my employer, do you have liability insurance to cover the expenses involved with adverse consequences to me because of my receiving the vaccine injections that you required as a condition of my continued employment?

Yes ____ No ____

If you do not have such insurance, are you willing and able to compensate my family reasonably in the event of my death attributable to the effects of having received the Covid 19 vaccine at your insistence?

Yes ____ No ____

If you answer Yes to any of the above, please identify your insurer:

Will you be providing Workers’ Compensation or disability insurance, or do you have other resources available if I have an adverse reaction to an EUA Covid-19 injection and am unable to work for days, weeks, or months, or if I am disabled for life?

Yes ____ No ____

If you answer Yes, please identify the program or resources you will rely on:

PART 3: Emergency Use Authorization (EUA)

The Covid 19 vaccines CURRENTLY BEING ADMINISTERED are allowed only under an EUA which means they are authorized, not approved.

Are you aware of this? Yes_____ No_____

Are you aware that the one approved vaccine, the Pfizer Cominarty, is not available and that only the EUA vaccines are being administered in the US?

Yes_____ No_____

The Food and Drug Administration (FDA) requires that all EUA vaccine recipients be provided with EUA fact sheets specific to each authorized Covid-19 injection. These sheets are published by the manufacturers of the injections and must provide the most current and up-to-date information on the injections, and any known adverse events. Please provide me with one of these fact sheets. While ignorance of the law does not relieve you of liability, were you aware this was a legal requirement

Yes_____ No_____ 

Have you reviewed the available databases of adverse events reported to date for people who have received Covid-19 injections, available at vaers.hhs.gov or openvaers.com? Yes _____ No _____

Are you aware that potential and reported adverse events include death, heart disease, anaphylaxis, neurological disorders, autoimmune disorders, other long-term chronic diseases, blindness and deafness, infertility, fetal damage, miscarriage, and stillbirth?  Yes _____ No _____

The FDA’s guidance on emergency approved medical products requires that the agency, “ensure that recipients are informed to the extent practicable given the applicable circumstances…[t]hat they have the option to accept or refuse the EUA product…”

Are you aware of this statement? Yes _____ No _____

Have you informed all employees that they have the option to refuse this experimental treatment? Yes _____ No _____

With respect to the emergency use of an unapproved product, the Federal Food, Drug and Cosmetic Act, Title 21 U.S.C. 360bbb-3(e)(1)(A)(ii)(I-III) restates the requirement that individuals must be informed of “the option to accept or refuse administration of the product, [and] of the consequences, if any, of refusing administration of the product, and of the alternatives to the product that are available and of their benefits and risks.” If EUA Covid-19 investigational vaccines are ever approved by the FDA, state legislation would be required to allow companies to mandate the Covid-19 injections.

Are you aware of these facts? Yes_____ No_____

EUA products are, by definition, untested, and experimental. Under the Nuremberg Code, the foundation of ethical medicine, no one may be coerced to participate in a medical experiment. The individual’s consent is essential. No court has ever upheld a mandate for an EUA vaccine. In Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003), a federal court held that the U.S. military could not mandate EUA vaccines for soldiers: “…[T]he United States cannot demand that members of the armed forces also serve as guinea pigs for experimental drugs”(Id. at 135).

Are you aware of this? Yes_____ No_____

The United States Code of Federal Regulations and the FDA require the informed consent of human subjects for medical research. The EUA Covid-19 injections are unapproved, unlicensed vaccines that are still in their experimental stage. It is unlawful to conduct medical research on a human being, even in the event of an emergency, unless steps are taken to secure the informed consent of all participants.

Are you aware of this? Yes _____ No _____

According to Federal Trade Commission (FTC) Guidelines and the FTC’s “Truth In Advertising,” promotional material — and especially material involving health-related products — cannot mislead consumers, omit important information, or express claims. Doing so falls under the rubric of “deceptive advertising” (whereby a company is providing or endorsing a product), whether presented in the form of an ad, on a website, through email, on a poster, or in the mail. For example, statements such as “all employees are required to get the Covid-19 vaccine to make the workspace safe” or “the shot is safe and effective” leave out critical information.  Critical information includes the facts that Covid-19 injections are unapproved EUA vaccines that “may” or “may not” prevent Covid, do not necessarily make the workspace safer, and could in fact cause harm. Failing to provide links to or attachments of the manufacturers’ fact sheets and current information on adverse events is omitting required safety information. Vaccine promoters routinely fail to provide required safety information. 

Are you aware of this? Yes _____ No _____

Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured Protected Health Information (PHI), incidents investigated by the Office for Civil Rights (OCR). These breaches exposed millions of people’s personal health information to unauthorized inspection. Although many of these incidents were attributed to hacking, some of the breaches to PHI fell directly under the 1996 Health Insurance Portability and Accountability Act (HIPAA), such as sharing a patient’s or person’s information with an unauthorized individual or incorrectly handling PHI. Can you please explain your obligations to me, under HIPAA law, and how you are going to protect my personal information, with respect to your requirement that I receive this injection?


Pharmaceutical companies that manufacture EUA vaccines have been protected from liability related to injuries or deaths caused by experimental agents since the 2005 PREP Act. Other companies and all other institutions or individuals who mandate experimental vaccines on any human being are NOT protected from liability. Are you aware that you do not enjoy such liability protection?

Yes _____ No _____

Are you aware that employees could file a civil suit against you should they suffer an adverse event, death, or termination from their place of employment?

Yes _____ No _____

Approval of Authorized Company Representative

As the legally authorized officer of the company, I have read this entire document and have provided my employees with all FDA required information for recipients of the Covid-19 injections. I hereby agree to assume 100% financial responsibility for all expenses arising from adverse medical events following injection with Covid-19 vaccines, including death, through insurance coverage or directly. In addition, I affirm that the employee would, in fact, NOT have been subjected to the loss of employment with this company should he or she have declined to receive an Covid-19 injection.

Signature: