Case 2:24-cv-02237-TLP-atc Document 1-4 Filed 04/16/24 Page 1 of 3 PageID 19
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`Case 2:24-cv-02237-TLP-atc Document 1-4 Filed 04/16/24 Page 1,
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`\Methodist |
`' LeBonheur Healthcare
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`MST)
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`| Date of Request:
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` ; ‘RequestorName:
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`Ragusa Enel auc Lc
` RequestorPhone:
`7 Supervisor:
`%
`Lak
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`MLH policy requiresall members ofthe workforce to receivethe COVID-19 vaccination. A religious exemption may be
`- - granted, subject to approval, if the individual holdssincere religious beliefs which are contrary tothe practice of
`;vaccination.
`if you seek a religious exemptionto the COVID-19 vaccine requirement, please submitthis eannpleted form
`ta Associateblealth@mih.ore.
`:
`Pleasenotethat philosophical, political,scientific, sociological or otherablections to:immunization (ratherthan sincerely :
`held religious beliefs).do not justify an exemption. While MLH will carefully. review all requests for religious exemptions, ae
`apptoval is not guaranteed, We may need to obtain additional information and/or documentationof-your‘religious.
`practice(s) or belief(s).- After-your request has been reviewed and processed, youwill be notifiediin writingifan 4 a
`sxemnpeh has been granted or denied.
`torthisisyspace baldw, lenteprovide a personal written statement detailing the religious basis for yourvaccination
`objection, explaining why you are requesting this religious exemption, the religious principle(s) that guideyour
`-
`objections to vaccination. Include whether you are opposedtoall immunizations and iif not, the:valkioysbasis‘that .
`protitbits COVID-19 in particular. Please attach additional documentation, if necessary.
`Soe Ottachod Staternont of baalinadlen,
`oe oteaVaddina HrOCRa Tea
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`

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`Case 2:24-cv-02237-TLP-atc Document 1-4 Filed 04/16/24 Page 2 of 3 PageID 20
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`_ Case 2:24-cv-02237-TLP-atc Document 1-4 Filed 04/16/24 Page2of3 PagelD 20
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`teto
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`__ Statementof Declination for Offer of Vaccine Products
`I, Audrey Ragsdale,a living woman retain and reserveall of my God-givenrights _
`including sole possession and soleuse of all my bislogical materials which are prankes
`me by my Creator.
`My employer, Methodist LeBonheur Healthcare, and location of éiriployment;
`Methodist NorthHospital, have offered vaccination products to me. | decline the offer”
`_ of vaccine products based onmysincerely-held religious beliefs, practices, and/or-
`observances.
`t retain the right to decline all attempts to access, influence and/or otherwise alter any.
`-and.all of my God-given biological material and/or biological systems which are unique,
`flawless and original design and craftsmanship of my Creator and of which my Creator
`has granted me solepossession, proprietorship and use of.
`yrequire, in accordance with 1 Corinthians 3:16-17 & 6:19-20 as a Temple of the Holy.
`Spirit, that-any and all products offered to me by my employeror workplace be both :
`entirely retrievable from and alsoremovable inits entirety from my body, person, and
`womanhood at the conclusion of each and every work period and/or workshift and also.
`and again at the completion of my contractual obligations with my location or .
`employment, and/or employer. Pursuantto> my above statement, decline the otherfor
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`all vaccination products.
`Pale
`“Because receiving the vaccine products would violate my sincerely-held religious beliefs,
`| hereby request accommodation of those beliefs with respect to the recently-imposed
`_ vaccination requirements. My accommodations are wearing one non-fitted surgical style
`mask and continue social distancing without being tested for Influenza or COVID. Having
`formally notified Methodist LeBonheur Healthcare of the conflict between the vaccine
`products and myreligious beliefs,
`| look forward to receiving ina prompt and timely
`_ manner yourdecision on what accommodation you will provide. Failing that, | reserve
`myright to pursue legal remedies available to mewith the Equal Employment
`Opportunity Commission or otherwise in accordance with established law.
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`“By: (dla Rasrdlt
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`(DATE F1RS|
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`Audrey Ragsdale
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`~All Rights Reserved
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`Case 2:24-cv-02237-TLP-atc Document 1-4 Filed 04/16/24 Page 3 of 3 PageID 21
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`Case 2:24-cv-02237-TLP-atc Document 1-4 Filed 04/16/24 Page 3of3 PagelD 21
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`, Methodist.
`y Le BonheurHealthcare
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` Requestor Name:
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`I certify that the above information is completeand accurate andthat| hold a sincere religious beliefthat is
`against the receiptof the COVID-19 vaccine.
`| understand that anyintentional misrepresentation containedin”
`. this request may resultin corrective action.| understandthatiffam granted this éxemption,I may.be required
`tocomaly with BAGONG!safety measures perpolicysuch asmasking/distancing.
`|
`As
`AU &ae
`laaidaVe — “eoyoverd date: _B-I9-D)
`Requestor Signature:
`By UQA
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`
`
`wo
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`Beet
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`
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`i Date Received
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`Exemption Granted? YES___
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`NO
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`Ifno, why? _
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