403.7E2 - 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

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Employee Signature                                                         Date

         

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Office Use

This request has been:

______________________________  ________________________________
Approved                                                                 Denied

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Administrator                                                                Date