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Date: |
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Employee Name: |
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Email Address: |
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Position/Job Title: |
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Employee Telephone Number: |
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Employment Location: |
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(1) What is the basis for the medical accommodation that you are requesting?
(2) What are you requesting an accommodation from?
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Item |
Yes/No |
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Vaccination for COVID-19 |
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Testing for COVID-19 |
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Use of Face Coverings |
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Employee Signature Date
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Office Use
This request has been:
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Approved Denied
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Administrator Date
