Vaccines authorized by the U.S. Food and Drug Administration in the United States are highly effective at protecting most fully vaccinated people against symptomatic and severe COVID-19. And here's Exhibit 2. Here Is Why the 6th Circuit Reinstated OSHA's Vaccine Mandateand Why One Judge Disagreed The argument hinges largely on what makes an emergency standard "necessary." Jacob Sullum | 12.20.2021 7 . &t@>/M(2Du^5;kMV7I6*^Cj=m`T]uz`Gz>FAQ\t;ciXInI5>q
g6| HNPn6,H{:?FYq7,BrWiBBn %\UnWY~>k}[huZk]pwpU.S5w{/q7e3Zzutx[0}sp0.2Ro&?`0D$`6=P?RL xGCz?Zl2&a7aWOt~f(uyw>v5?S.Hx5 p<1+t`3bW 0\9HUfZW=\LKDEGuN$^iy$UR:5JxqGm0wxt{;Z~GVh@e&)IUtSA-($OLg!IuW3 People are considered fully vaccinated for COVID-19 two weeks or more after they have completed their final dose of a COVID-19 vaccine authorized for Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration in the United States. Personal and political beliefs do not qualify employees for vaccination exemptions. In fact, labor lawyers said that OSHA has indicated it prefers employers to mandate . 3. Fully vaccinated people in areas of substantial or high transmission should be required to wear face coverings inside (or other appropriate PPE and respiratory protection) as well. However, CDC recognizes that even some fully vaccinated people who are largely protected against severe illness and death may still be capable of transmitting the virus to others. Learn about and take advantage of opportunities that your employer may provide to take time off to get vaccinated. Barriers should block face-to-face pathways between individuals in order to prevent direct transmission of respiratory droplets, and any openings should be placed at the bottom and made as small as possible. This guidance is designed to help employers protect workers who are unvaccinated (including people who are not fully vaccinated) or otherwise at-risk (as defined in the text box below), including if they are immunocompromised, and also implement new guidance involving workers who are fully vaccinated but located in areas of substantial or high community transmission. Labor lawyers say this is within OSHAs legal authority. Will the vaccine-or-test requirements apply to remote workers and those who work outside? Since the advent of the COVID-19 vaccines early in 2021, potential religious exemptions to mandatory vaccine requirements have been a challenging legal issue and focus of debate. Occupational Safety & Health Administration, Occupational Safety and Health Administration, Outreach Training Program (10- and 30-hour Cards), OSHA Training Institute Education Centers, July 27, 2021 Centers for Disease Control and Prevention (CDC) mask and testing recommendations for fully vaccinated people, What Workers Need To Know about COVID-19 Protections in the Workplace, The Roles of Employers and Workers in Responding to COVID-19, Appendix: Measures Appropriate for Higher-Risk Workplaces with Mixed-Vaccination Status Workers, areas of substantial or high community transmission, Interim Public Health Recommendations for Fully Vaccinated People, update recommendations for fully vaccinated people, Vaccines for People with Underlying Medical Conditions, What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws, Centers for Disease Control and Prevention, safe and healthy workplace free from recognized, tax credits under the American Rescue Plan, Implementing Protections from Retaliation, OSHA Alert: COVID-19 Guidance on Ventilation in the Workplace, Minimum Efficiency Reporting Value (MERV) 13, suspected of having or confirmed to have COVID-19, CDC cleaning and disinfection recommendations, reporting COVID-19 fatalities and hospitalizations to OSHA, educating and training workers about COVID-19 policies and procedures, Guidance for COVID-19 Prevention in K-12 Schools, Severe Storm and Flood Recovery Assistance, Protecting Workers: Guidance on Mitigating and Preventing the Spread of COVID-19 in the Workplace, Reorganize Appendix recommendations for Manufacturing, Meat and Poultry Processing, Seafood Processing, and Agricultural Processing Industries, Add links to guidance with the most up-to-date content, choosing to wear a mask regardless of level of transmission, particularly if individuals are at risk or have someone in their household who is at increased risk of severe disease or not fully vaccinated; and. OSHAs rule will affect some 84 million private-sector workers across the country, including some 31 million who are believed to be unvaccinated. ;]!1s_A{z )YIBcxx7%:\u~zb"YNYxNY4nrTw"3\usu'x^3t_}J(:8s#L4/76;V1vO3O]Jpgfa
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x7i_H$^u}4Mf"iD?-Ed-l Who will pay for those tests? In a 5-4 ruling, the Supreme Court held that the CMS Rule "fits neatly within the language . Confined spaces without adequate ventilation increase the risk of viral exposure and transmission. The latest federal vaccine mandate covers 84 million workershere's what to know. CDCs definition of masks includes those that are made of cloth, those that are disposable, and those that meet a standard. These responses will be updated, posted and shared to promote full . %PDF-1.5
have until Jan. 4 to ensure all their workers, unlikely to reach the United States market anytime soon, will end its aggressive but contentious vaccine mandate, a previous set of emergency temporary standards, A court temporarily blocked the rule on Nov. 6, about 80 percent of adults in the United States had been vaccinated. Require unvaccinated or otherwise at-risk workers, and also fully vaccinated workers in areas of substantial or high community transmission, to wear masks whenever possible, encourage and consider requiring customers and other visitors to do the same. These COVID-19 prevention programs include measures such as telework and flexible schedules, engineering controls (especially ventilation), administrative policies (e.g., vaccination policies), PPE, face coverings, physical distancing, and enhanced cleaning programs with a focus on high-touch surfaces. OSHA has determined that it would not be feasible for employers to permit exemptions based on prior infection. The Supreme Court on Thursday issued mixed rulings in a pair of cases challenging Biden administration COVID-19 vaccine mandates, allowing the requirement for certain health care workers to go . All rights reserved. Its also worth noting that the remote worker exemption doesnt apply to employees who travel, Duston says. Those states rules are required to be at least as effective as the federal governments. See ORS 433.416 (3). This follows the Supreme Court's decision . 3 The CDC and the Department of Education have addressed situations where a student cannot wear a mask because of disability. A sample COVID-19 Vaccine Exemption form is included along with the letter. While this guidance addresses most workplaces, many healthcare workplace settings will be covered by the mandatory OSHA COVID-19 Emergency Temporary Standard. The Biden administration released new guidance on Thursday about implementing the COVID-19 vaccine mandate for federal employees, which says even those on telework or remote work must get vaccinated. Multi-layered controls tailored to your workplace are especially important for those workers who are unvaccinated or otherwise at-risk. Note on recording adverse reactions to vaccines: OSHA, like many other federal agencies, is working diligently to encourage COVID-19 vaccinations. 4. CEI Research Fellow Sean Higgins warned that the impact on [] The new masking, testing, and vaccine requirements put in place by the Occupational Safety and Health Administration are expected to cover 84 million employees, but there are key exemptions that could ease the strain on some employers. The CMS Rule was immediately challenged in dozens of states. CMS will be taking action to require COVID-19 vaccination for workers in most health care settings that receive Medicare or Medicaid. See CDCs Guide to Masks. Employers should engage with workers and their representatives to determine how to implement multi-layered interventions to protect unvaccinated and otherwise at-risk workers and mitigate the spread of COVID-19, including: Facilitate employees getting vaccinated. The Marin County Department of Public Health and Safety is operating a vaccine clinic in what once was a Victorias Secret store at the Northgate Mall in San Rafael, Calif. |'f$) X*dsgF m(-Q;?6zs)]UfYU/`! More unvaccinated workers will be required to get the Covid-19 vaccine by Jan. 4 or face regular testing under . A three-judge panel on the Fifth Circuit court on Friday did rule to permanently block the vaccine rule, but many employers are still working to comply since many experts predict the Supreme Court will need to ultimately decide the fate of the mandateand that will likely take place after some of OSHAs deadlines have passed. Not only are independent contractors not covered by the mandates, they also do not count toward the 100-employee threshold, according to the Department of Labor. It can touch off an allergic reaction for a small number of people. Make sure all workers wear appropriate face coverings in areas of substantial or high community transmission. The U.S. Centers for Disease Control and Prevention (CDC) reports in its latest Interim Public Health Recommendations for Fully Vaccinated People that infections in fully vaccinated people (breakthrough infections) happen in only a small proportion of people who are fully vaccinated, even with the Delta variant. OSHAs rule applies to the private sector, including nonprofits. Employers have to provide paid time off for their workers to get vaccinated, up to four hours, as well as paid sick leave for them to recover from side effects. OSHA will update this guidance over time to reflect developments in science, best practices, and standards. The religious and medical exemptions will come into play here but when it comes to people who do not have exemptions, employers are generally free to discipline people who dont follow their rules. ma3Y;Em5ei8[nVIw2zSAJr
PikUmC;H!\,|l?9Yy>F*6O^Hbzl Employers should also consider working with local public health authorities to provide vaccinations in the workplace for unvaccinated workers. This could include posting a notice or otherwise suggesting or requiring that people wear face coverings, even if no longer required by your jurisdiction. If an employee works by themselves, they may also be exempt from the vaccine and testing requirements. 2. Do employers have to provide their workers with paid time off for Covid testing? It will also enforce the rules. Some means of tracking which workers have received this information, and when, could be utilized by the employer as appropriate. The deadline for employers to enforce the mask mandate is Dec. 5. However, certain states have their own workplace safety rules that extend to the public sector as well. PEG is used in a wide range . =434+/1vrw@rtJ>vn^j2t 'Y|82/X^BvK=pEPn[8pu99F4znfJur`OrOrO?W}a
+jiEdVas'!^]n.:i(/K]~1mX_3"{Am~=_IoET@F\,V,yU*DUOLAwDg9j"=m[:CnC[9ysv.AfQrijM] Follow our latest coverage here: Corporate America has entered the next phase of its effort to counter the spread of the coronavirus. There are a lot of workplaces you may think of as outdoorthe construction industry is one of themthat are never 100% outdoors, Duston says. Fully vaccinated people who have had close contact should get tested for COVID-19 3-5 days after exposure and be required to wear face coverings for 14 days after their contact unless they test negative for COVID-19. S&P Index data is the property of Chicago Mercantile Exchange Inc. and its licensors. Employees exempt by law: Most workplaces can require employees to get a COVID-19 vaccine, but some types of workers are exempt by law. A majority of the Supreme Court has placed the OSHA vaccine or testing mandate on hold. Many employers require people to present a doctors note to qualify for this exemption. Implement protections from retaliation and set up an anonymous process for workers to voice concerns about COVID-19-related hazards: Section 11(c) of the OSH Act prohibits discharging or in any other way discriminating against an employee for engaging in various occupational safety and health activities. When an employer determines that PPE is necessary to protect unvaccinated and otherwise at-risk workers from exposure to COVID-19, the employer must provide PPE in accordance with relevant mandatory OSHA standards and should consider providing PPE in accordance with other industry-specific guidance. People with certain medical conditions or disabilities are exempt from the mandate because they are protected under the Americans with Disabilities Act. Employers should also consider working with local public health authorities to provide vaccinations for unvaccinated workers in the workplace. Does OSHAs rule cover health care workers? There were about 10.6 million independent contractors, or about 6.9% of total employment, in the U.S. as of 2017, according to the Bureau of Labor Statistics latest report, released in 2018. Paragraph (d)(2) is a limited exemption from the mandatory vaccination policy requirement of paragraph (d)(1). Cloth face coverings may be commercially produced or improvised (i.e., homemade) and are not considered personal protective equipment (PPE). Earlier this year, companies that implemented vaccine mandates on their own saw a dramatic uptake of vaccinations among their workers. If barriers are used where physical distancing cannot be maintained, they should be made of a solid, impermeable material, like plastic or acrylic, that can be easily cleaned or replaced. x47 POFl~qx1%RY]gP~(gOS@CT5LQ:K]>j+ix)\~S3 a~}zBkjr9gZ{ {u^6l; Space such workers out, ideally at least 6 feet apart, and ensure that such workers are not working directly across from one another. Employers should consider taking steps to protect these at-risk workers as they would unvaccinated workers, regardless of their vaccination status. Requests for religious exceptions have recently surged, some are protected by law. Unless otherwise provided by federal, state, or local requirements, workers who are outdoors may opt not to wear face coverings unless they are at risk, for example, if they are immunocompromised. Employers could also limit the number of unvaccinated or otherwise at-risk workers in one place at any given time, for example by implementing flexible worksites (e.g., telework); implementing flexible work hours (e.g., rotate or stagger shifts to limit the number of such workers in the workplace at the same time); delivering services remotely (e.g., phone, video, or web); or implementing flexible meeting and travel options, for such workers. Nearly half of full-time U.S. employees, about 45%, were still fully or partially working from home as of September, according to Gallups polling. 653, 655 (c), 657 ), to protect unvaccinated employees of large employers (100 or more employees) from the risk of contracting COVID-19 by strongly . In these types of higher-risk workplaces which include manufacturing; meat, seafood, and poultry processing; high-volume retail and grocery; and agricultural processing settings this Appendix provides best practices to protect unvaccinated and otherwise at-risk workers. Certain companies might decide to apply their policies more widely, including to volunteers. Guidance posted January 29, 2021; UpdatedJune 10, 2021. Workers who are unable to produce proof of vaccination can instead use a signed and dated document to attest that they are vaccinated and that they lost or cannot produce the standard proof. I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.. Labor lawyers said that if related companies are managed in a way that combines control of occupational safety and health measures, then their employees should be counted together toward the 100-worker threshold. This rule does not cover health care workers because there was a previous set of emergency temporary standards specific to the health care industry, which faces more stringent vaccine requirements. Stagger break times in these generally high-population workplaces, or provide temporary break areas and restrooms to avoid groups of unvaccinated or otherwise at-risk workers congregating during breaks. Is it legal for employers to require vaccines without giving workers an option to instead submit to testing? Do part-timers and contractors count toward the 100-worker threshold? OSHA released its long awaited emergency temporary standard (ETS) on Nov. 4 calling for employers with 100 or more employees implement vaccine mandates by Jan. 4, 2022, or ensure that unvaccinated . [d;G meZSn%WaSI_`VBu!bP"_!s7'8`"r2*LWug!TPWF!ubMP%pcf4"4>%d>Z} qT):bn2,>_ EU5i)xj~={rnv3q@}@m;r/h7[Ic;#Vm,Zu36:I%7m_KNcBSlt$JcF~,Ur)iz'J@%`lnJz2~:uf%~:l07blP,wH9Cr 3. This "emergency temporary standard" by the Occupational Safety and Health Administration (OSHA) is expected to apply to some 84 million people and be in effect by January 4. OSHAs rule says the attestation should include the following language: I declare (or certify, verify, or state) that this statement about my vaccination status is true and accurate. attention is whether workers can seek religious exemptions from company-imposed vaccine . The BBP standard illustrates congressional understanding that . 2 People who are not fully vaccinated should be tested immediately after being identified (with known exposure to someone with suspect or confirmed COVID-19), and, if negative, tested again in 57 days after last exposure or immediately if symptoms develop during quarantine. Keep in mind that before the vaccines were available, many companies had masking policies in place that applied to employees, customers, visitors, and vendors. Employers should provide face coverings to workers who request them at no cost (and make replacements available to workers when they request them). Now that counties have authority over COVID-19 mitigation efforts, do businesses still need to follow OSHA's guidance? Finally, OSHA provides employers with specific guidance for environments at a higher risk for exposure to or spread of COVID-19, primarily workplaces where unvaccinated or otherwise at-risk workers are more likely to be in prolonged, close contact with other workers or the public, or in closed spaces without adequate ventilation. Companies of 100 or more employees have until Jan. 4 to ensure all their workers are either fully vaccinated or submit to weekly testing and mandatory masking. Employees supplied by staffing agencies can be excluded from counts as well, since they would be counted by the agency. For operations where the face covering can become wet and soiled, provide workers with replacements daily or more frequently, as needed. This F.A.Q. January 13, 2022 Update: The Supreme Court ruled to block the proposed vaccine-or-test mandate . Who will determine those exceptions? Employers are expected to keep documentation of their workers vaccination status, such as a copy of their vaccination cards or a signed and dated employee attestation. It is up to employers to determine who qualifies for a religious exemption from getting the vaccine on a case-by-case basis. OSHA-2021-0007 an can be submitted electronically to http . However, preliminary evidence suggests that fully vaccinated people who do become infected with the Delta variant can be infectious and can spread the virus to others. Statement on the Status of the OSHA COVID-19 Vaccination and Testing ETS (January 25, 2022) The U.S. Department of Labor's Occupational Safety and Health Administration is withdrawing the vaccination and testing emergency temporary standard issued on Nov. 5, 2021, to protect unvaccinated employees of large employers with 100 or more employees from . No. OSHA is charged with assuring that employers provide safe workplaces for their . Ensure that absence policies are non-punitive. The Occupational Safety and Health Act gives OSHA authority to respond quickly to emergency situations when workers are confronted with grave threats. In short, Congress has not given OSHA license to mandate COVID-19 vaccines. Labor lawyers argue that a company must have at least 100 United States-based employees to be covered by OSHAs rule. The measure was announced by President Biden in September, and details were released on Nov. 4 by the Labor Departments Occupational Safety and Health Administration. Although OSHAs mandate covers a broad swath of employeestemporary workers, seasonal workers, and minorsthe agencys rules do not generally apply to those who are self-employed, including independent contractors. Among other things, the ETS requires that covered employers must implement and enforce a policy that mandates that employees be fully vaccinated against COVID-19 by January 4, 2022 or to submit to . OSHA also explained that companies in a franchise relationship need to only count workers who work out of the corporate or principal office. The deadline for workers to be fully vaccinated is Jan. 4. OSHA strongly encourages employers to provide paid time off to workers for the time it takes for them to get vaccinated and recover from any side effects. In a workplace, workers often are required to work in close proximity to each other and/or customers or clients for extended periods of time. The real benefit for employers who issue a vaccine mandate is saved for last in OSHA's explanation. It contains recommendations as well as descriptions of existing mandatory OSHA standards, the latter of which are clearly labeled throughout. Which vaccines count toward the requirement? Exempt workers include: firefighters, law enforcement officers, corrections officers, or parole and probation officers. OSHA decided that its rule would apply to businesses of at least 100 workers because it was confident they would have the administrative capacity to put it into effect. Prepare Your Business to Comply With the OSHA Vaccine Mandate. Once OSHAs rule is put in place, what portion of the American population is expected to be vaccinated? CDC provides information on the benefits and safety of vaccinations. Employers mandating vaccines are adhering to OSHAs requirements and most likely cant be held liable for any adverse effects. Under federal law, employers have a lot of discretion in granting the requests. Those workers who have not yet been fully vaccinated will need to start wearing face masks in the workplace starting Dec. 5, according to the new regulation. OSHA is considering whether to extend the rule to employers with fewer than 100 workers. Powered and implemented by Interactive Data Managed Solutions. To understand more about these conditions, see the CDC's page describing Vaccines for People with Underlying Medical Conditions and further definition of People with Certain Medical Conditions. Photo courtesy of the Supreme Court of the United States December 23, 2021 September 27, 2021 2:02 PM EDT. Particles containing the virus can travel more than 6 feet, especially indoors and in dry conditions (relative humidity below 40%), and can be spread by individuals who do not know they are infected. Suggest or require that unvaccinated customers, visitors, or guests wear face coverings in public-facing workplaces such as retail establishments, and that all customers, visitors, or guests wear face coverings in public, indoor settings in areas of substantial or high transmission. c+z[
[VK0r>Q8F<2nBeElZ;]"1^`2RmM i[HH1A?WC!ZvBZ)}vQA5pv*4-Uc>]:}>`wVvRbnS#;'C As a result, OSHA will not enforce 29 CFR part 1904s recording requirements to require any employers to record worker side effects from COVID-19 vaccination at least through May 2022. Unless you are fully vaccinated and not otherwise at-risk, stay far enough away from other people so that you are not breathing in particles produced by them generally at least 6 feet (about 2 arm lengths), although this approach by itself is not a guarantee that you will avoid infection, especially in enclosed or poorly ventilated spaces. Always cover your mouth and nose with a tissue, or the inside of your elbow, when you cough or sneeze, and do not spit. 3 0 obj
2.1 Federal guidance on vaccine mandates 2.2 Advantages of vaccine mandates vs. "vaccinate or test" 2.3 List of companies in Pennsylvania mandating vaccination 2.4 Resources supporting staff vaccination 2.5 Verifying and tracking employee vaccination status 2.6 Handling vaccine exemptions and exemption requests 3 Testing employees Shared closed spaces such as break rooms, locker rooms, and interior hallways in the facility may contribute to risk. Particles containing the virus can travel more than 6 feet, especially indoors and in dry conditions with relative humidity below 40%. A Biden administration mandate will require businesses with 100 or more employees to implement a vaccine and COVID testing policy by January 4 or face fines. A well-maintained ventilation system is particularly important in any indoor workplace setting and when working properly, ventilation is an important control measure to limit the spread of COVID-19. More information is available on OSHA's website. HIGHLIGHTS FROM THE EEOC'S UPDATED GUIDANCE ON RELIGIOUS EXEMPTIONS This directive went into effect on Nov. 1, 2022. Who does the directive apply to? All Rights Reserved. Vaccine mandates will be required as a condition of Medicare/Medicaid reimbursement. This F.A.Q. Other workers may want to use PPE if they are still concerned about their personal safety (e.g., if a family member is at higher risk for severe illness, they may want to wear a face shield in addition to a face covering as an added layer of protection). Postal Service in 8 charts Adjust stocking activities to limit contact between unvaccinated and otherwise at-risk workers and customers. <>/ExtGState<>/Font<>/Pattern<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 22 0 R 25 0 R 26 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
Employers can, however, adjust their routines and procedures to accommodate this, says law firm Fisher & Phillips. Individuals may choose to submit adverse reactions to the federal Vaccine Adverse Event Reporting System. Lawmakers needn't prohibit OSHA from imposing a mandate that they never authorized the agency to issue in the first place. In fact, labor lawyers said that OSHA has indicated it prefers employers to mandate the vaccine. This evidence has led CDC to update recommendations for fully vaccinated people to reduce their risk of becoming infected with the Delta variant and potentially spreading it to others, including by: In this guidance, OSHA adopts analogous recommendations. President Joe Biden's Nov. 4, 2021, vaccine mandate would have forced millions under a vaccine mandate, notably for businesses with over 100 employees. But OSHA does note that if employees are occasionally required to perform in-person work, they must be fully vaccinated or obtain a negative test result within seven days of heading into the office. According to the CDC, a growing body of evidence suggests that fully vaccinated people are less likely to have symptomatic infection or transmit the virus to others. CDC has also updated its guidance for COVID-19 prevention in K-12 schools to recommend universal indoor masking for all teachers, staff, students, and visitors to K-12 schools, regardless of vaccination status.3 CDC's Face Mask Order requiring masks on public transportation conveyances and inside transportation hubs has not changed, but CDC has announced that it will be amending its Face Masks Order to not require people to wear a mask in outdoor areas of conveyances (if such outdoor areas exist on the conveyance) or while outdoors at transportation hubs, and that it will exercise its enforcement discretion in the meantime. Some conditions, such as a prior transplant, as well as prolonged use of corticosteroids or other immune-weakening medications, may affect workers' ability to have a full immune response to vaccination. By Julia Zorthian. Examples of violations of Section 11(c) could include discriminating against employees for raising a reasonable concern about infection control related to COVID-19 to the employer, the employer's agent, other employees, a government agency, or to the public, such as through print, online, social, or any other media; or against an employee for voluntarily providing and safely wearing their own PPE, such as a respirator, face shield, gloves, or surgical mask. The OSHA Rule requires covered employers to develop, implement, and enforce either a mandatory COVID-19 vaccination policy, or a policy requiring employees to get vaccinated or undergo weekly . In addition, mandatory OSHA standard 29 CFR 1904.35(b) also prohibits discrimination against an employee for reporting a work-related illness. More information on COVID-19 is available from the Centers for Disease Control and Prevention. Alabama passed a law last month setting forth new requirements for mandatory vaccine exemptions, which are further described below. The Occupational Safety and Health Administration (OSHA) is also expected to unveil a rule as early as this week that will likely detail the compliance requirements applicable to employers with 100 or more employees to mandate vaccines or require regular testing. Religious exemptions from company-imposed vaccine charged with assuring that employers provide safe workplaces for their s... Exemption doesnt apply to remote workers and customers & # x27 ; s Exhibit 2 and... That OSHA has indicated it prefers employers to mandate COVID-19 vaccines employers require people to present a doctors to... 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