403.7E2 - Medical Accommodation Request Form

MEDICAL ACCOMMODATION REQUEST FORM

Date:

 

Employee Name:

 

Email Address:

 

Position/Job Title:

 

Employee Telephone Number:

 

Employment Location:

 

(1)     What is the basis for the medical accommodation that you are requesting?

(2)     What are you requesting an accommodation from?

Item

Yes/No

Vaccination for COVID-19

 

Testing for COVID-19

 

Use of Face Coverings

 

 

 

___________________________________              ________________________________

Employee Signature                                                                Date

 

 

 

 Office Use

This request has been:

 ______________________________                        ________________________________

Approved                                                                                Denied

 

_________________________________                  ______________________________

Administrator                                                                          Date