Fillable A. Questions to clarify accommodation requested. (Please attach (College of Wooster)

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A. Questions to clarify accommodation requested. (Please attach (College of Wooster)

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Name:_____________________________________ Employee ID: ________________________
A. Questions to clarify accommodation requested. (Please attach additional pages if needed)
What serious chronic medical condition(s) have you been diagnosed with by your physician and what
type of medical
treatment(s) are you receiving for this condition(s)?
What specific accommodation(s) are you requesting?
What is the name, address and phone number of your treating physician?
What is the date of your last examination/visit with this physician?
B. Questions regarding job duties, functions & accessibility. (Please attach additional pages if needed)
Provide a description of your current job duties.
What job duties do you perceive could be performed from home and how (be very detailed)?
Do you have VPN access, internet access and equipment necessary to perform your job from home?
Please specify
below:
REASONABLE ACCOMMODATION REQUEST FORM FOR COVID-19
C. Certification and Signature
I certify that the information provided is true and accurate.
Date
of Request: _________________
Signature: ___________________________
Notes for HR Use Only:
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A. Questions to clarify accommodation requested. (Please attach (College of Wooster)

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Completed 19 August 2020

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