Introduction
The policy statement, the purpose of the form, and what the form says does not qualify for an exception.
GSA19R
Request for a Religious Exception to the COVID-19 Vaccination Requirement
- Agency
- GSA
- Revision
- Rev. 2/2022
- Fillable fields
- 13
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 19R: Request for a Religious Exception to the COVID-19 Vaccination Requirement
GSA Form 19R is the Request for a Religious Exception to the COVID-19 Vaccination Requirement. The footer reads GENERAL SERVICES ADMINISTRATION and GSA 19R (REV. 2/2022), and GSA hosts it in its forms library. GSA's page lists the authority or regulation as 5 U.S.C. § 2105 and says the form is for GSA employee use only.
The form says government-wide policy requires all Federal employees, as defined in 5 U.S.C. § 2105, to be vaccinated against COVID-19, with exceptions only as required by law, and that its purpose is to determine whether the employee may be eligible for an exception. An employee who receives one would instead comply with alternative health and safety protocols.
The form has an employee information block, three questions, a signed declaration and a Privacy Act Statement on the back. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 19R
Employee info
Employee name, date of request, GSA staff or service office, office, division or branch, position, the employee's supervisor and a telephone number.
Questions 1 and 2
The nature of the objection, and whether complying would substantially burden religious exercise or conflict with sincerely held religious beliefs, practices, or observances, and how.
Question 3
Any additional information, with examples: how long the belief has been held, which vaccines the objection covers, and whether other vaccines such as flu or tetanus were received as an adult.
Declaration and signature
A declaration that the answers are true and correct to the best of the employee's knowledge and ability, with signature, name and date.
Privacy Act Statement
On the back: statutory authority, purpose and use, routine uses under GSA/HRO-1, and the consequence of not supplying the information.
How to complete GSA Form 19R
- 1
Fill in the employee info
Enter name, date of request, office, division or branch, position, supervisor and telephone number.
- 2
Answer question 1
Describe the nature of the objection to the COVID-19 vaccination requirement.
- 3
Answer question 2
Say whether complying would substantially burden religious exercise or conflict with sincerely held beliefs, practices or observances, and if so, explain how.
- 4
Add anything else in question 3
The form invites any additional information that may help in reviewing the request, and lists three examples.
- 5
Sign and date
Sign the declaration and enter the name and date. The form says signing constitutes a declaration that the information is true and correct.
Why fill Form GSA19R on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the GSA, not a copy someone retyped
- Works on a phone, tablet or computer
Routing and what the form says
Where it goes
The form prints no address or office to send it to. It says the agency may ask for other information as needed.
What the form says does not qualify
The form says a refusal to be vaccinated does not qualify for an exception if it is based upon personal preference, concerns about the possible effects of the vaccine, or political opinions.
Privacy
The Privacy Act Statement says requesting a reasonable accommodation is a voluntary process and access is limited to individuals with a need to know, under the System of Records Notice GSA-HRO-1.
Authority
GSA's page lists 5 U.S.C. § 2105. The Privacy Act Statement lists 29 U.S.C. § 791, 42 U.S.C. § 12101, 42 U.S.C. § 2000e-16, 29 U.S.C. § 2601, 40 U.S.C. § 3173 and E.O. 13164, 13548, 14042 and 14043.
False statements
The form says any intentional misrepresentation to the Federal Government may result in legal consequences, including termination or removal from Federal Service.
Related forms
Who fills out GSA Form 19R?
GSA's page says the form is for GSA employee use only.
Official sources and the blank
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Questions about Form GSA19R
Who issues GSA Form 19R?
The footer reads GENERAL SERVICES ADMINISTRATION and GSA 19R (REV. 2/2022). GSA hosts it in its forms library, and GSA's page says the form is for GSA employee use only.
What does GSA Form 19R ask?
Three questions: the nature of the objection, whether complying would substantially burden religious exercise or conflict with sincerely held religious beliefs, and any additional information that may help in reviewing the request.
What examples does question 3 give?
How long the religious belief has been held, whether the objection is to all vaccines, COVID-19 vaccines, a specific type of COVID-19 vaccine or some other subset, and whether vaccines against other diseases were received as an adult.
Can the agency ask for more information?
The form says the agency may ask for other information as needed to determine if the employee is legally entitled to an exception.
What does the form say about false information?
It says signing constitutes a declaration that the information is true and correct, and any intentional misrepresentation may result in legal consequences, including termination or removal from Federal Service.
Is there a medical version of this form?
Yes. GSA Form 19M is the Request for a Medical Exception to the COVID-19 Vaccination Requirement, also dated REV. 2/2022 and also for GSA employees.