Vaccination and Exemption Questionnaire (Exhibit A) — Lancione v. Mass General Brigham

Summary

Exhibit A, a Plaintiff Questionnaire in Lancione v. Mass General Brigham (Case 1:21-cv-11686-FDS, Document 71-1, Filed 03/11/22), asks about employment with a Mass General Brigham ("MGB") entity, COVID-19 and adult vaccination history, and requests for religious or medical exemption under MGB's Vaccination Policy, the mandatory employee COVID-19 vaccination policy MGB announced on or about August 10, 2021. Other questions cover remote or hybrid work, social media posts opposing COVID-19 vaccines or vaccine mandates, and fact witnesses. A verification page has the plaintiff declare the answers true under penalty of perjury, and ADMIT or DENY statements follow.

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Full text

Exhibit A
Exhibit A
Case 1:21-cv-11686-FDS   Document 71-1   Filed 03/11/22   Page 1 of 14

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2.  Employment with a Mass General Brigham (“MGB”) Entity.1
Entity Name, Position Held in 2021:
Direct Manager’s name in 2021:
Date of Suspension under the Vaccination Policy2:
Date of Termination under the Vaccination Policy (if any):
Vaccination Status and History
COVID-19 Vaccinations.
3. Have you ever received a vaccination for COVID-19? Yes
  No
If yes, please fill out the chart below.  Attach a copy of any records of your COVID-19
vaccinations.
Date
Location Where
Vaccination Administered
Manufacturer of vaccine
Adult Vaccination History.
4. For any vaccinations you have received as an adult (i.e., since turning the age of 18), please
fill out the chart below.  Attach a copy of any records of those vaccinations.
Date
Type of Vaccination
Was the Vaccination
Required for
Employment? (Indicate
YES or NO)
1 MGB refers to any member hospital, medical center, or other medically-related organization
within the MGB healthcare system.
2 The “Vaccination Policy” refers to the mandatory employee COVID-19 vaccination policy
MGB announced on or about August 10, 2021.
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Date
Type of Vaccination
Was the Vaccination
Required for
Employment? (Indicate
YES or NO)
5.  Have you tested positive for COVID-19?  Yes
  No
If yes, state the date(s) on which you tested positive. ___________________________________
Request(s) for Exemption Under MGB’s Vaccination Policy
6. Please indicate which exemption(s) you claim to have requested under MGB’s Vaccination
Policy (check either that applies or both if you requested both):
Religious Medical  
7. For any exemption request that you claim to have sought under the Vaccination Policy, please
identify anybody who assisted you, or any resources you consulted or relied on (including
websites)in writing or preparing the exemption request and/or any subsequent submissions in
support of the request by filling out the chart below.  Attach a copy of any documents concerning
that assistance including any drafts of your exemption request(s) or subsequent submissions.
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Name of Person,
Website, or
Other Resource
(If a Person)
Current or Last
Known Address
or (if website)
URL
(If a Person)
Relationship to
You
Type of
Assistance
or Resource
Provided
(If You Paid
for This
Assistance or
Resource)
Amount Paid,
Date of
Payment, and
to Whom Paid
8. Please identify any communications you had with MGB employees or any other persons —
other than e-mails to or from MGBReligiousExemptions@Partners.org, or
PHSOHSCovid19@partners.org— about your exemption request(s) by providing: (a) the person
with whom you communicated, (b) the date of the communication, (c) the form of
communication (e.g., email, phone call, oral conversation), and (d) the substance of the
communication. Use the space below for your answer.  Attach a copy of any documents that
constitute, reflect, or relate to any communications identified in your answer.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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9. Do you contend that you worked for MGB either remotely or under a hybrid in-person/remote
arrangement between January 1, 2019 and the date of your termination (or, if you have not been
terminated, the present)? Check the option that applies:
Remote Hybrid 
Neither (I worked in person) 
10. If you selected either remote or hybrid, please indicate below during what time period(s) you
were remote or hybrid, and identify each instance, between January 1, 2019 and the date of your
termination (or, if you have not been terminated by MGB, the present), in which you have been
present onsite on the premises of an MGB facility, using the chart provided.
Time periods in which you were remote or hybrid:_____________________________________
Date(s)
Name of MGB Entity
Reason/s for Presence on Site
Religious Exemptions.
11. If you indicated above that you sought a religious exemption, please state the name of the
religion, if any, to which you adhered at the time you requested the exemption and when you
allege you began adhering to such religion:
_____________________________________________________________________________
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12. In the space below, please briefly describe the evidence on which you intend to rely to
support your claim that you had a (i) sincere (ii) religious belief that (iii) conflicted with the
Vaccination Policy at the time you requested an exemption.  Attach a copy of any documents on
which you intend to rely.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
13. Have you ever previously sought an accommodation from MGB, or any other employer, for
the belief(s) or practice(s) you described in your previous answer?
Yes
 No
If yes, please fill out the information in the chart below.
Date of
Accommodation
Request
Name of
Employer
Nature of
Accommodation
Requested
Was the
Accommodation
Granted? (YES
or NO)
If YES, Specify
Time Period for
Which
Accommodation
Was Granted
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Medical Exemptions.
14. If you indicated above that you sought a medical exemption, please provide information
about any medical conditions for which you claim to have requested an exemption under the
Vaccination Policy by filling out the chart below.
Medical
Condition
Date of
Diagnosis
Treating Healthcare Provider(s) (Include Name
and Address)
15. Do you contend that the medical condition(s) for which you sought an exemption is/are a
Centers for Disease Control contraindication to the COVID-19 vaccine?  Explain your answer in
the space below and attach any documents that support your contention.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
16. Do you contend that any of the medical condition(s) for which you sought an exemption
substantially limits a major life activity (e.g., seeing, hearing, walking, lifting, speaking)?
Yes
 No
If yes, please explain using the space below.  Attach a copy of any documents that support your
contention.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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17. Have you ever previously sought an accommodation from MGB, or any other employer, for
the medical condition(s) you described in your previous answer?
Yes
 No
If yes, please provide the information about any such accommodations using the chart below.
Attach a copy of any documents concerning your prior requests for accommodation.
Date of
Accommodation
Request
Name of
Employer
Nature of
Accommodation
Requested
Was the
Accommodation
Granted? (YES
or NO)
If YES, Specify
Time Period for
Which
Accommodation
Was Granted
Social Media.
18. Identify any social media accounts (e.g., Facebook, Instagram, Twitter, YouTube, Whatsapp,
TikTok, LinkedIn) or online forums (including but not limited to the comments sections of
online publications, websites or social media posts) on which you have discussed your
employment with MGB or an MGB entity, or the COVID-19 vaccine or vaccine mandates, by
filling out the chart below.
Name of Social Media
Platform Or Online Forum
User Name
Date Began Using
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19. For any of the social media accounts or online forums listed above, identify in the space
below any statuses, posts, comments, messages, or any other communications you have made in
opposition to COVID-19 vaccines or vaccine mandates by stating: (i) the name of the social
media platform or online forum, (ii) the date, and (iii) the substance of the status, post, comment,
message, or communication.  Please provide any copies of the communications you identify in
your answer.
Note: to provide copies of any communications identified, you may use “screenshots.”  Any
screenshots of communications should include enough of the status, post, comment, message, or
other communication to show the context.  For example, a screen shot of a comment should
include the content to which the comment responded or related.  Any screenshots should be
marked with the date and time on which the screenshot was taken.  If you provide screenshots in
response to this question, you still have a duty to preserve any and all electronically-stored
versions of the communications and you may be later asked to provide further information or
documents about the communications.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Fact Witnesses
20. Please identify any persons whom you intend to call as witnesses in this action and, for each,
state the person’s name, address, relationship to you (if any), and a description of the information
you believe the person possesses.  Use the spaces provided below.
Name:
Address:
City:_______________________________ State:___________ Zip:
Relationship:
Information they possess:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name:
Address:
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City:_______________________________ State:___________ Zip:
Relationship:
Information they possess:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name:
Address:
City:_______________________________ State:___________ Zip:
Relationship:
Information they possess:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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VERIFICATION
I, ______________________________, declare under the penalty of perjury subject to 28
U.S.C. § 1746 that all of the information provided in this Plaintiff Questionnaire is true,
complete, and correct to the best of my knowledge, information, and belief, that I have supplied
all the documents requested in this Questionnaire, and that I have signed and supplied the
authorization attached to this Verification.
Further, I acknowledge that I have an obligation to supplement the above responses if I
learn they are incomplete or incorrect, or if new information becomes available.
____________________________________
____________________
Signature

Date
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4.
During my workday when working on-site at an MGB entity, I have removed my mask
indoors to eat or drink.
ADMIT _____

DENY _____
5.
I understand that it is possible to test negative for the COVID-19 virus one day and be
positive the next day, or even two days later.
ADMIT _____

DENY _____
6.
I am aware of one or more instances of transmission of COVID-19 (staff to staff, or staff
to patient) within an MGB entity that occurred during the period I worked at MGB.
ADMIT _____

DENY _____
7.
During my employment with MGB, I understood that all personnel at MGB entities,
regardless of whether they have a remote work status, are subject to being called in to the
worksite as needed.
ADMIT _____

DENY _____
8.
I have been on-site at an MGB entity, on a paid work shift, at least once since January 1,
2019.
ADMIT _____

DENY _____
9.
I was redeployed to a position different from my usual position at MGB at least once
during the COVID-19 pandemic.
ADMIT _____

DENY _____
10.
Putting aside any request for exemption(s) from the COVID-19 vaccine at MGB, I have
never asked an employer for any disability accommodation.
ADMIT _____

DENY _____
Plaintiff’s Signature:_________________________________________ Date:_____________
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