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

 

___________________________________  ________________________________
Employee Signature                                                         Date

         

--------------------------------------------------------------------------

Office Use

This request has been:

______________________________  ________________________________
Approved                                                                 Denied

_______________________________________________________________
Administrator                                                                Date