Employee Health & Wellness

COVID-19 Vaccine Mandate FAQs

• Who is covered under this federal regulation?

  This federal regulation applies to the following individuals, both current and new, regardless of clinical responsibility or patient contact:

  • All UTMB employees, including faculty
  • Licensed practitioners, including community physicians with UTMB privileges
  • Students
  • Trainees
  • Volunteers
  • Contracted staff
• Would a physician with admitting privileges in one of UTMB's hospitals be covered under this regulation?
  Yes, a physician admitting and/or treating patients in-person within a UTMB facility is subject to the CMS health and safety regulations and included as a part of this regulation must be vaccinated so that UTMB is compliant.
• When must individuals be vaccinated for UTMB to remain compliant with this regulation?

  CMS established the deadlines by which covered Texas facilities must comply with the COVID vaccination mandate. The deadlines are:

  • Phase 1: Covered individuals must have received 1) at least one dose of a two-dose vaccine; 2) an approved qualifying exemption; or 3) approval for a CDC-recommended temporary delay (such as after a recent COVID antibody treatment) by 11:59 p.m., Feb. 20, 2022.
  • Phase 2: Covered individuals must have received 1) the second dose of a two-dose vaccine; 2) a single-dose vaccine; 3) an approved qualifying exemption; or 4) approval for a CDC-recommended temporary delay by 11:59 p.m., March 20, 2022. Please note: CMS will not take enforcement action if 90% of covered individuals are fully vaccinated (or granted exemptions or temporary delays) by the Phase 2 deadline and UTMB has a plan to achieve 100% compliance within 30 days of receiving a noncompliance notice from CMS.
  • April 20, 2022: The latest possible deadline for UTMB to reach 100% compliance (including full vaccinations, exemptions and temporary delays) to avoid enforcement action by CMS, if Phase 1 and Phase 2 benchmarks are met.

  UTMB estimates it will achieve the 90% compliance threshold by 11:59 p.m., March 20, 2022. Therefore, all employees, students, volunteers and contractors are required to be fully compliant by 11:59 p.m., April 19, 2022.

• How does CMS define “fully vaccinated” for the purposes of this regulation?

  For purposes of this regulation, CMS currently considers individuals fully vaccinated if it has been two weeks or more since they completed a primary vaccination series for COVID-19. However, individuals who have completed the primary series for the vaccine received by 11:59 p.m., April 19, 2022, are considered to have met these requirements, even if they have not yet completed the 14-day waiting period required for full vaccination.

  The completion of a primary vaccination series for COVID-19 is defined in the rule as the administration of a single-dose vaccine (such as the Janssen (Johnson & Johnson) COVID-19 Vaccine), or the administration of all required doses of a multi-dose vaccine (such as the Pfizer-BioNTech COVID-19 Vaccine (interchangeable with the licensed Comirnaty Vaccine) or the Moderna COVID-19 Vaccine). Additionally, individuals who receive vaccines listed by the World Health Organization (WHO) for emergency use that are not approved or authorized by the FDA or as a part of a clinical trial are also considered to have completed the vaccination series in accordance with CDC guidelines.

• Which vaccines count toward the regulation?

  CMS expects that staff will receive a vaccine licensed or authorized for emergency use by the Food and Drug Administration (FDA), which currently includes the Pfizer-BioNTech COVID-19 Vaccine (interchangeable with the licensed Comirnaty vaccine), Moderna COVID-19 Vaccine, and the Janssen (Johnson & Johnson) COVID-19 Vaccine. Facilities will also be in compliance if they allow staff to work who received a vaccine listed by the World Health Organization (WHO) for emergency use that is not approved or authorized by the FDA, or who received a vaccine during their participation in a clinical trial.

• What if an individual received a vaccine outside of the United States?

  CMS expects that vaccine administration will occur within the United States for the majority of individuals and that those will receive a COVID-19 vaccine authorized for emergency use or licensed by the FDA. However, it is permissible to receive a COVID-19 vaccine outside of the United States. Eligible COVID-19 vaccinations administered to individuals outside of the United States include those that are FDA licensed or authorized for emergency use or those that are listed by the WHO for emergency use.

• Does “fully vaccinated” include additional doses or booster shots? For example, a third dose of mRNA vaccines is now recommended for individuals who are immunocompromised, and boosters are recommended or available for individuals who are 65 or older?

  For purposes of this regulation, CMS currently considers individuals fully vaccinated if it has been two weeks or more since they completed a primary vaccination series for COVID-19. However, individuals who have completed the primary series for the vaccine by 11:59 p.m., April 19, 2022, are considered to have met these requirements, even if they have not yet completed the 14-day waiting period required for full vaccination. A third dose or booster shot is not required to be considered fully vaccinated. 

  The completion of a primary vaccination series for COVID-19 is defined in the rule as the administration of a single-dose vaccine (such as the Janssen (Johnson & Johnson) COVID-19 Vaccine), or the administration of all required doses of a multi-dose vaccine (such as the Pfizer-BioNTech COVID-19 Vaccine (interchangeable with the licensed Comirnaty Vaccine) or the Moderna COVID-19 Vaccine).

• What if an individual received a mix of vaccines as part of their COVID-19 primary vaccination series? Does that count toward the vaccination requirement?

  Yes, individuals may be considered compliant with the requirements within this regulation if they have received any combination of two doses of a vaccine licensed or authorized by the FDA or listed on the WHO emergency use list as part of a two-dose series.

• Will there be different requirements for individuals currently associated with UTMB and new employees, students, volunteers or contractors?

  No, all individuals to whom the vaccine requirement applies must be in full compliance by 11:59 p.m., April 19, 2022, prior to providing any care, treatment or other services for UTMB and/or its patients.

• Does the regulation include testing requirements for unvaccinated individuals?

  CMS provided additional guidelines to mitigate the spread of COVID-19, and UTMB created a risk reduction plan to comply with this mandate requirement. Beginning Feb. 21, 2022, all employees, students, volunteers and suppliers/contractors who are not fully vaccinated (i.e., have only received one dose of a two-dose vaccine) or who have been granted an exemption or temporary delay from the vaccine must adhere to the following risk reduction plan:

  • Masking: Individuals with direct patient-facing duties will be required to wear a fit-tested N95 mask during any direct patient care duties and KN95 masks in non-clinical areas. Individuals without direct patient-facing duties will be required to wear a KN95 mask during all interactions with others. This includes during meetings/classroom instruction and in all facility hallways, breakrooms, restrooms, elevators, etc.
  • Weekly Testing: When positivity rates in our region are equal to or greater than 10%, weekly COVID testing will be required for anyone who is not fully vaccinated, regardless of role at UTMB. Individuals subject to this requirement will be notified when any future required testing period begins and ends.
• Are exemptions allowed?

  Yes, UTMB will allow for the following exemptions in accordance with federal law:

  • Recognized medical conditions for which vaccines are contraindicated or because you are subject to a CDC-recommended vaccine deferral; and
  • Religious beliefs, observances or practices.

  For CDC guidance regarding medical exemptions, click here. For EEOC guidance regarding religious exemptions, click here. 

• Is there provision for certain individuals for whom a vaccination should be delayed, for example, because of a recent COVID-19 diagnosis?

  Yes, this regulation allows for individuals for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and consideration. Individuals subject to a CDC-recommended deferral should request a medical exemption through the established process. 

• Does the regulation include exemptions for individuals that show they have COVID-19 antibodies?

  No, individuals who have previously had COVID-19 are not exempt from these vaccination requirements. Available evidence indicates that COVID-19 vaccines offer better protection than natural immunity alone and that vaccines, even after prior infection, help prevent reinfections. CDC recommends that all people be vaccinated, regardless of their history of symptomatic or asymptomatic SARS-CoV-2 infection.

• What is the process for requesting a medical exemption?

  Individuals who are not capable of being vaccinated due to a medical condition for which vaccines are contraindicated or who are subject to a CDC-recommended vaccine deferral may request an exemption. See above for the appropriate exemption request form.

  All medical exemption requests must include a completed medical certification from the individual's personal health care provider. For CDC guidance regarding medical exemptions, click here.

  UTMB has established a Medical Exemption Committee to review all requests for a medical exemption. Members of the committee are appointed by UTMB General Counsel. Individuals seeking a medical exemption will be notified in writing of the status of their request. 

• What happens if an individual is not able to obtain a medical certification from their health care provider before the Feb. 11, 2022, exemption request deadline?

  Requests for both medical and religious exemptions will be accepted after the Feb. 11, 2022, deadline; however, UTMB must adhere to the 11:59 p.m., April 19, 2022 , deadline imposed by the federal vaccine mandate. Individuals should submit a complete exemption request as soon as possible. UTMB has established committees to review all requests for exemption, and it is the committees’ goal to review the requests quickly so as not to interfere with an individual’s ability to continue working, studying or volunteering at UTMB. 

• Why might an individual request a religious exemption?

  Individuals should request a religious exemption if there is a conflict between the requirement to be vaccinated and sincerely held religious beliefs, practices or observances. Please note that social, philosophical, political or economic views and/or other personal preferences will not meet the criteria for an approved exemption and accommodation request.

• What is the process for requesting a religious exemption?

  Individuals who are not capable of being vaccinated due to religious beliefs, observances or practices may request an exemption. See above for the appropriate form. For EEOC guidance regarding religious exemptions, click here.

  UTMB has established a Religious Exemption Committee to review all requests for a religious exemption. Members of the committee are appointed by UTMB General Counsel. Individuals seeking a religious exemption will be notified in writing of the status of their request. 

• Why might an individual’s request for an exemption be denied?

  An individual's exemption request will be denied if, based on the committee’s review, it does not meet the criteria for an approved exemption and accommodation request.

• What if an individual was denied for a religious exemption but others with the same beliefs were approved?

  Each religious exemption request is considered on a case-by-case basis. There are no blanket approvals or denials based upon similar beliefs.

• If an individual’s request for an exemption was denied, are they able to appeal the decision?

  Exemption decisions are final and cannot be appealed. However, an individual can submit a new form to provide clarifying or additional information for the committee to evaluate.

• What should an employee do if they were vaccinated at UTMB but received an email indicating we do not have a COVID-19 vaccination record on file for them?

  If an employee was vaccinated at UTMB but received an email indicating the institution does not have a COVID-19 vaccination record on file for them, the employee should email a scan of their COVID-19 Vaccination Record Card to Employee Health at emphlthc@utmb.edu with their employee ID in the subject line. 

  Students who do not already have their vaccine record on file should upload their COVID-19 Vaccination Card using this online form.

• With the changes to the CDC guidance for the vaccine intervals, what will happen if an individual now needs to get a second dose after April 19, 2022?

  Under the amended CDC guidance, individuals 12 through 64 years of age and who are not moderately or severely immunocompromised may receive their second mRNA vaccine dose eight weeks after their first dose, instead of after three to four weeks. UTMB employees, students, volunteers and contractors who fall into this category and have received their first dose of COVID mRNA vaccine in the past four weeks will be allowed eight weeks for the second dose.

  • If you received your first dose of a COVID mRNA vaccine on or after Jan. 31, 2022, you will be allowed 60 days to receive the second dose. You have been given an approved CDC-recommended temporary delay, allowing you the time to be safely vaccinated and comply with the mandate.
  • If you received your first dose of a COVID mRNA vaccine before Jan. 31, 2022, you will need to receive the second dose by 11:59 p.m., April 19, 2022.

  Ultimately, all partially vaccinated employees need to fully comply by 11:59 p.m., April 19, 2022. Failure to achieve full compliance will result in termination from UTMB.

• What happens if an employee does not take any action by 11:59 p.m., April 19, 2022?

  If you are not fully compliant with the mandate by 11:59 p.m., April 19, 2022, your employment with UTMB will be terminated effective April 20, 2022. You will not be able to extend your separation date by using your accruals or a leave of absence without pay.

• How does receipt of an intent to terminate notice affect an employee’s annual performance review?

  Receiving an intent to terminate notice will not have an effect on an employee’s annual performance review. The intent to terminate notice is a procedural requirement that must be met before UTMB terminates certain employees. 

  UTMB decided to present these notices to all employees who are not yet fully compliant with the vaccine mandate to provide ample time for them to understand the timeline for compliance and the consequences of non-compliance and to act accordingly. If the employee achieves full compliance by the stated deadline, UTMB will not proceed with the termination, and the notice of intent to terminate is considered voided. 

• How will this regulation be enforced?

  CMS expects state survey agencies to conduct onsite compliance reviews of these requirements in two ways:

  • State survey agencies would assess all facilities for these requirements during the standard recertification survey.
  • State survey agencies would assess vaccination status of staff on all complaint surveys.

  While onsite, surveyors will review UTMB's COVID-19 vaccination policies and procedures, the number of resident and staff COVID-19 cases over the last 4 weeks, and a list of all staff and their vaccination status. This information, in addition to interviews and observations, will be used to determine the compliance of the provider or supplier with these requirements. Additionally, accrediting organizations will be required to update their survey processes to assess facilities they accredit for compliance with vaccination regulations.